Inspection·August 26, 2024

F 0758 Level of Harm - Actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to report adverse side effects immediately, failed to monitor the use of psychotropic medications, and failed to carry out the orders to hold medication for a resident showing signs of adverse effects of excessive drowsiness. This failure resulted in R1 being sent out to the hospital for evaluation for stroke like symptoms. This applies to 1 of 3 residents (R1) reviewed or unnecessary medications in the sample of 5. The findings include: R1's face sheet shows she is [AGE] year-old female with diagnosis including somnolence (excessive drowsiness 8/15/24), altered mental status (8/15/24), unspecified dementia with other behavioral disturbance, heart disease, delusional disorder, anxiety disorder, unspecified hearing loss, vascular dementia with psychotic disturbance, mood (affective) disorder, and glaucoma. R1's hospital Records dated 8/15/24 documents [AGE] year-old female with a history of vascular dementia and behavioral disturbances presents with acute encephalopathy and lethargy likely suspect due to polypharmacy. R1's hospital discharge medication list dated 8/16/24 shows a decrease dose in her psychotropic medications including Depakote 125 mg (milligrams) two capsules three times a day and Seroquel 50 mg twice a day. On 8/22/24 at 9:19 AM, R1 was observed in her lying in bed. R1 was yelling and calling out from her room. V7 (Registered Nurse/RN) entered the room to assist R1, using the communication board to ask R1 what she needed. R1 was not able to verbally express her needs to V7. R1 was on the call light frequently and yelling when staff left the room. At 9:54 AM, V9 and V10 (Certified Nursing Assistant's-CNA's) provided care to R1 including incontinence care and transferring her from the bed to the wheelchair using a mechanical lift. R1 did not display behaviors of aggression, combativeness, and was compliant with all cares. On 8/22/24 at 9:38 AM, V7 (RN) said R1 has behaviors of combativeness and agitation. She was hospitalized in June and sent to behavioral health. She had a change in her psychotropic medications due to lethargy. She has been okay since her dose was decreased. She still has some behaviors of yelling out and screaming, but is more awake. If a resident is showing adverse effects from the medication, nursing should hold the medication and notify the physician. On 8/26/24 at 8:57 AM, V5 (Unit Manager) said R1 is alert, confused, and has behaviors of crying, screaming, restlessness, agitation, and combative during cares. Lately she has periods of sleepiness (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 3 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 08/26/2024 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)