Inspection·July 24, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect a resident's right to be free from misappropriation of resident property. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 8. Residents Affected - Few The findings include: R1's face sheet list her diagnoses to include: urine retention, urinary tract infection, atrial fibrillation, heart failure, unilateral primary osteoarthritis of the left knee, morbid obesity, anxiety, osteoarthritis, muscle weakness and a history of malignant neoplasm of the breast. On July 24, 2024 at 8:45 AM, R1 was lying in bed watching television. She stated, she stole 30 of my pills. She stated, she told him (V5 Unit Manager) she (R1) was feeling dizzy but she never said that. The facility did call the police and they came and talked with her and her daughter. She stated, she didn't know her name but she was chubby and had curly hair. The facility's final incident report dated July 22, 2024 shows, Resident Name: (R1). Date of incident: 7/18/2024. Incident category: resident misappropriation of property/theft. Summary of incident: On 7/18/2024 the nurse manager (V5 Unit Manager) reported that the resident's Norco (pain medication) 7.5/325 mg (milligram) 30 tablets were missing. The Norco was delivered on 7/16/2024 in a bingo card [sic] with 30 tablets Based on investigation, on 7/17/2024 approximately 4:00 PM, resident (R1) was complaining of pain to her left knee and was asking if she can take Norco. The PM agency nurse on duty was not able to find Norco in narcotic box. The NP (Nurse Practitioner) was noted to have written a new script of Norco on 7/15/2024. The pharmacy reported that the Norco was delivered on 7/16/2024 early AM delivery and was received by the night nurse. The PM nurse on duty reported to the nurse manager that she cannot locate the Norco that was delivered early that day . On 7/17/2024, the AM nurse (V4 LPN/Licensed Practical Nurse) was interviewed and stated initially that the resident complained of feeling dizzy with the Norco and she notified the doctor about the resident's complaint and received an order for Tramadol (pain medication). Nurse Manager (V5 Unit Manager) reached out to the doctor for the Tramadol order, but the doctor stated she did not receive any phone call from the AM nurse (V4 LPN). The Nurse Manager (V5 Unit Manager) called (V4 LPN) back and let her know that the doctor was stating that she did not receive any phone call from (V4 LPN) and there was no order of Tramadol in PCC (a computer program used for electronic charting). The nurse manager (V5 Unit Manager) explained to (V4 LPN) that she needs to be honest and explained what happened to the Norco because we are going to notify the Police and (State Agency). (V4 LPN) sent an email to the Nurse Manager (V5 Unit Manager) that night stating she admitted to taking the Norco home with her because she has been having a hard time and has no insurance to pay for her medication (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145341 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Encore Village 350 West Schaumburg Road Schaumburg, IL 60194 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)