Encore Village: Wrong Medications Sent Home With Resident - IL
The mix-up at Encore Village, documented by inspectors on August 20, 2025, involved a resident identified in the inspection report as R1, who had been staying at the facility for respite care and brought her own medications with her. Those medications were stored in the facility's medication cart. Also in that cart sat a bag of pill bottles belonging to a different resident, R3, which the Director of Nursing later acknowledged should have been returned to R3's family before any of this happened.
At some point during a night shift, an unidentified nurse cleaned out the medication cart. Two of R3's pill bottles had apparently fallen loose from his bag during that cleaning. The nurse picked them up and put them into R1's bag. The Director of Nursing, identified in the report as V2, said the nurse should have checked the name on each pill bottle before placing it anywhere. Nobody did.
When R1 was discharged, the nurse handling the process, identified as V4, was supposed to go through each medication individually with the resident and her family, reviewing dosages, how often to take each one, and what side effects to watch for. V2 described this as standard discharge procedure: sit with the resident and family, open the bag, go through every medication one by one.
That didn't happen the way it should have. V2 said that V4 should have reconciled R1's medications independently after another staff member, V7, declined to do so, and before handing the bag over. V4 did not. R1 left the facility with the bag, and R3's pill bottles went with her.
The inspection report does not say what medications were in R3's bottles, how many doses were involved, or whether R1 took any of them before the error was discovered. It does not describe any harm to R1. The violation was cited at the level of minimal harm or potential for actual harm.
What the report makes clear is that at least three separate failures had to line up for this to occur. Someone had to leave R3's bag of unused medications sitting in the cart instead of returning it to his family. An unknown night-shift nurse had to pick up two loose pill bottles and drop them into the wrong bag without reading the label. And the nurse handling R1's discharge had to hand over that bag without going through each medication and catching what didn't belong.
V2 did not dispute any of this. She described each failure plainly, including the one involving her own nursing staff's refusal to reconcile the medications before discharge. She said the nurse who cleaned the cart should have checked the name on every bottle. She said V4 should have done the reconciliation herself regardless of V7's refusal. She said R3's bag should have been returned to his family before the incident ever had a chance to happen.
The facility's own discharge policy, dated February 2024, requires that a discharge summary include a complete accounting of every medication a resident is taking, with dosages, how often to take each one, and information about significant side effects. The policy exists precisely because medication errors at discharge are dangerous. A resident going home with the wrong pills, or with someone else's pills added to their own, may not know the difference.
R1 went home not knowing the difference.
The inspection report does not say whether the facility contacted R1's family after discovering the error, whether the pill bottles were recovered, or whether R3's family was notified that his medications had been sitting loose in a cart and then sent out the door with a stranger.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Encore Village from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
ENCORE VILLAGE in SCHAUMBURG, IL was cited for violations during a health inspection on August 20, 2025.
Those medications were stored in the facility's medication cart.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.