Inspection·October 31, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 staff failed to ensure residents who required staff assistance with Activities of Daily Living (ADLs) received timely incontinence care for 2 of 4 residents (R2, R1) reviewed for ADLs in the sample of 9. Residents Affected - Few The findings include: 1. R2's care plan dated 9/23/24 showed R2 required staff assistance with toileting and transferring. R2's resident assessment dated [DATE] showed R2 was frequently incontinent of urine and stool. On 10/31/24 at 8:44 AM, R2 was asleep in bed. A strong odor of urine was noted in her room. On 10/31/24 at 9:15 AM, R2 was awake, lying in bed. R2 stated, No one has come in yet this morning. I was last changed (provided incontinence care) late last night. The urine odor remained in R2's room. On 10/31/24 at 9:17 AM, V5 Certified Nursing Assistant (CNA) entered R2's room to provide cares. V5 (CNA) stated she had not toileted or provided incontinence care to R2 yet during her shift. As V5 (CNA) removed R2's incontinence brief, V5 stated, She's pretty wet. R2's brief was saturated with urine. Urine had leaked out of R2's brief, onto her shirt, pants, and bedding. 2. R1's care plan dated 10/22/24 showed R1 required staff assistant with toileting. The care plan showed R1 was frequently incontinent of urine and stool. On 10/31/24 at 8:40 AM, R1 was seated in a wheelchair in her room. R1 wore a gown. A urine odor was noted in her room. R1 stated staff got her up around 8 AM that morning, but did not toilet her or change her incontinence brief. R1 said, I wear a diaper. I think I am wet right now. When R1 was asked why staff didn't change her brief when they got her out of bed, R1 stated, I don't know. R1 denied refusing to be toileted that morning or refusing to have her incontinence brief changed. On 10/31/24 at 9:16 AM, R1 remained seated in her wheelchair, eating breakfast in her room. On 10/31/24 at 10:19 AM, R1 had finished eating breakfast. V6 (CNA) entered R1's room to provide cares. V6 (CNA) transferred R1 to the toilet. R1's incontinence brief was saturated with urine. R1's buttocks were bright pink. Urine had leaked out of R1's brief onto the pad on her wheelchair. V6 (CNA) was asked why R1 was not toileted upon getting her out of bed that morning. V6 stated, She refused this morning. R1 immediately turned to V6 and stated, I most certainly did not! (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 4 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 10/31/2024 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)