Inspection·November 7, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to keep a resident free from physical abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. The findings include: R1's face sheet showed she was admitted to the facility 2/13/24 with diagnoses to include dementia without behavioral disturbance, polyosteoarthritis, atrial fibrillation, hypertension, and frontotemporal neurocognitive disorder. R1's facility assessment dated [DATE] showed she has severe cognitive impairment. R2's face sheet showed she was admitted to the facility 8/28/24 with diagnoses to include age-related osteoporosis, epilepsy, rheumatoid arthritis, anxiety disorder, dementia with agitation, and neurocognitive disorder with behavior disturbance. R2's facility assessment dated [DATE] showed she has severe cognitive impairment. R2's care plan initiated 6/21/24 showed, [R2] has begun to have behaviors related to refusal of direct care. 8/16/24 and 8/17/24: Disruptive, acting out behaviors with staff and peers. Much yelling and throwing of beverages at different people. calmed with removal from environment and reduced stimulation . R2's care plan initiated 10/31/24 showed, The resident is/has, potential to demonstrate physical behaviors related to dementia. Resident noted on 10/27/24 to grab another patients wrists when she mistakenly believed that the other resident was in her room . Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document . Modify environment: Image of hot cup of tea placed on bathroom door to encourage resident to exit shared bathroom toward the correct room . R2's 10/27/24 Behavior Note showed, At 7:20 PM CNAs notified nurse that patient was in [R1's] room being aggressive with another patient. Nurse was also notified that she had injured the other patient. Nurse delegates removal of patient to the nurse desk for monitoring. Patient still being aggressive, did not want to stop yelling and leave room . R1's 10/27/24 Health Status Progress Note showed, Nurse attends to patient after incident. Patient states her left shoulder and hip hurt. Nurse notes 2 cuts on patient: left wrist and right pinky. Also, noted bruise on outer part of left hip. Nurse cleansed, measures and covered skin tears. Patient states being scared and not feeling safe. Nurse comforts patient and reassured patient that she is safe now . NP (Nurse Practitioner) has requested X-rays for hip and shoulder. (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: 145312 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 145312 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Symphony Northwoods 2250 Pearl Street Belvidere, IL 61008 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)