Inspection·August 20, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to reconcile a residents' (R1) discharge medications with current prescription orders prior to discharging the resident. This failure affected two of three residents (R1, R3) reviewed for medications in the sample of three and resulted in several of R3's medications being found within R1's accompanying medications after discharging home.The findings include: On 08/20/2025, review of R1's Discharge summary dated [DATE] showed no documentation under sections for medication list, medication reconciliation, or medication review. On 08/20/2025, review of grievance/concern forms showed a concern for R1 dated 08/13/2025 that indicated V7 reported a medication mix-up to V2 (DON). Family concern documentation provided by V2 indicated that V7 contacted the facility on 08/13/2025 (day after R1's discharge) to report two medication bottles not prescribed to the resident were found among [R1's] discharge belongings. Documentation then indicated during the discharge process, while packing medications and cleaning the medication cart simultaneously, there was a likely mix-up due to two medication bags being in close proximity that may have resulted in a medication bottle intended for another resident being mistakenly placed in [R1's] discharge bag. On 08/20/2025 at 12:29 PM, V4 (Registered Nurse) said R1 came to the facility on [DATE] under respite (short-term) care and admitted with a plastic zip lock bag filled with her home medications that were within labeled pill bottles from her pharmacy. V4 added that R1's medications were stored in the medication cart within the plastic bag. V4 added that R1's medication list was inputted into her electronic medical record and her medications were removed from the appropriate pill bottles during her scheduled administration times. On 08/20/2025 at 12:34 PM, V4 said on the morning of 08/12/2025 around 8:30 AM, R1's daughter (V7- Family Member) arrived at the facility and quickly packed R1's belongings then informed V4 that she was taking R1 home. V4 said she indicated to V7 that she needed to review and reconcile with them R1's discharge orders and medications but V7 said she was in a hurry and just wanted to take R1 home with her bag of medications. V4 stated that she just took the bag of meds out of the cart and gave it to her daughter without checking any of the bottles. V4 then said that she did not reconcile R1's discharge medication orders with the medication bottles within the plastic bag prior to giving them to V7 which is part of the discharge process to ensure we are sending all the correct medications and doses home with the resident. On 08/20/2025 at 12:39 PM, V4 added that R3 had recently admitted to the facility with a similar plastic bag full of home medications that were also stored in the med cart but were not being used during R3's scheduled administration times because the facility utilized the medication bubble cards provided by the facility's pharmacy. V4 said both R1 and R3's bags of medications were stored next to each other in the med cart, and that she was unsure how or when some of R3's pill bottles were placed inside of R1's med bag because she had been off for several days prior to R1's day of discharge. V4 added that she did not clean out the med cart nor add R3's pill bottles to R1's medication bag upon her discharge. On (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 08/20/2025 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)