Inspection·March 12, 2025

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 Based on interview and record review the facility failed to protect a resident from the misappropriation of resident property when a credit card was stolen from a resident's room for 1 of 2 residents (R2) reviewed for the misappropriation of resident property in the sample of 3. Residents Affected - Few The findings include: The Final Incident Report dated 12/20/24 for R2 showed, Incident category: Resident misappropriation of property/theft. Summary of Incident: The resident is a long-term resident of the facility and is alert and oriented x 3 (person, time, & place); she is forgetful at times. On 12/17/24 the unit manager received an email from the police department detective. He was seeking assistance to identify a photo of the person within the email. The individual in the picture is presumed to be the individual who used the credit card of R2 at a store. The unit manager immediately reported to the interim administrator regarding the email received. The unit manager and ADON (Assistant Director of Nursing) reached out to POA (Power of Attorney), daughter of the resident. The POA stated that she realized that the credit card was not in the possession of the resident because she reviewed the monthly statement and that is when she saw a purchase made at a store. On 12/18/24 the unit manager was able to speak with the detective. The unit manager relayed to the detective that the individual in the picture did not work at the facility. The unit manager informed the detective of the CNA (Certified Nursing Assistant) who provided care to the resident during the same day when the credit card was used. The POA - daughter reached out to the credit card company was able to reverse the charges that were incurred. The POA then reached out to the police and filed a complaint. This is an ongoing investigation with the police. The facility will continue to assist law enforcement however we can. On 3/11/25 at 11:42 AM, V10 (R2's POA/daughter) stated, R2 wanted the credit card for incidentals. V10 stated she gets the credit card statements. V10 stated she reviewed the credit card statement and looked at it a few weeks later. She saw a charge dated 10/1/24 for a gaming system at a store for $500.00. V10 stated she notified the manager; she left a message. V10 stated she talked to R2 to see if she wanted the police involved and she did. V10 stated she contacted the police, and the detective has the dates. V10 stated the detective has been keeping in contact with the facility. V10 stated the police suspect that the person that used the credit card was someone that knew someone at the facility. They think an employee gave the card to someone else that used it. On 3/11/25 at 12:12 PM, V6 (Executive Director), V9 (Social Services), and V5 (Registered Nurse/Unit Manager) were presented information together and stated that theft should not occur at the facility. On 3/11/25 at 2:56 PM, R2 was sitting in a wheelchair in her room. R2's cell phone had a case around it with a card holder built into the case. R2 stated her credit card was stolen and had been in (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 6 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 03/12/2025 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)