Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed ensure safe incontinence care for 1 of 3
residents (R1) reviewed for safety. This failure resulted in R1 rolling off the bed onto the floor and sustaining
a cervical fracture, a left clavicle fracture, and laceration to her left eyebrow requiring 3 sutures.
The findings include:
R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dysphagia,
hyperlipidemia, Type 2 Diabetes, spondylosis without myelopathy, generalized anxiety, depression, and
arthropathy. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and
requires substantial to maximum assist for bed mobility.
R1's care plan initiated 6/5/23 showed, . Self care deficit, requires staff assist with ADLs (activities of daily
living)related debility, weakness . Bed Mobility- extensive assist Toileting - extensive assist, incontinence
care .
On 1/2/25 at 11:00 AM, R1 was lying in her bed. R1 had a brace on her neck and a sling on her left arm.
R1's acute care hospital documentation dated 12/29/24 showed, . Today's Visit . Reason for Visit: Fall .
Diagnoses: Other closed nondisplaced fracture of first cervical vertebra, Closed nondisplaced fracture of
acromial end of left clavicle, eye laceration Avulsion of skin of left forearm .
R1's facility incident report dated 12/29/24 showed, 12/29/24, at approximately 1:18 AM the resident was
reportedly receiving care when the resident rolled out of the bed and landed on her left side. The resident
sustained a laceration to the left eyebrow and a skin tear to the left elbow. First aid was immediately
rendered. the resident complained of left shoulder pain . The resident was transferred to the local ED
(emergency department) via EMS (emergency medical services) where the laceration to the left eyebrow
was repaired with three sutures. Additional imaging was performed which displayed new fracture of the C1
vertebrae and acute fracture of the distal clavicle .
R1's 12/28/24 nursing note entered at 1:03 PM showed, Alert, pleasantly confused and able to make needs
known. Compliant with medications, took crushed in applesauce without difficulty. Appetite adequate and
ate both breakfast and lunch in the dining room. able to propel self short distances in wheelchair, without
difficulty. Incontinent of bowel and bladder, peri care provided PRN (as needed). Resident up in wheelchair
at this time near nurses station. No complaints of signs and symptoms of
(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 3
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
01/02/2025
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)
F 0689
pain/discomfort verbalized or displayed .
Level of Harm - Actual harm
R1's 12/29/24 nursing note entered at 1:29 AM showed, Resident was being changed by CNA (Certified
Nursing Assistant) at the time of fall. Resident rolled to her right side and she didn't stop rolling which
resulted in fall to floor. Landed on her left side on floor. Received cut to left upper, outer eyebrow and a left
elbow skin tear. Areas cleaned and dressing applied to left elbow. Pressure held to left eyebrow until
bleeding stopped. Resident hoyer lifted back to bed. Complained of left shoulder pain. On call NP notified
Resident taken by EMS (emergency medical services) to [acute care hospital] .
Residents Affected - Few
R1's 12/29/24 nursing note entered at 4:16 AM showed, MD (Medical Doctor) called . Resident being
transferred to [a neighboring acute care hospital] for admission due to a C1 (cervical vertebrae) fracture .
R1's 12/29/24 nursing note entered at 5:41 AM showed, . ER (Emergency Room) called facility and resident
is to return to the facility. Need to make appointments with ortho and neurosurgery on Monday. PRN (as
needed) Tramadol (pain medication) ordered . Resident came back by ambulance at this time. Aspen collar
(neck stabilizer) on and sling to left arm due to collarbone fracture .
R1's care plan initiated 4/6/23 showed, Potential for falls, Resident at risk for injury from falls . Interventions:
(12/29/24) 2 staff assist resident with turning and repositioning in bed for cares . Aspen collar at all times,
may release for skin checks and hygiene . Sling to LUE (left upper extremity) at all times, may remove for
showers/skin checks .
On 1/2/25 at 1:06 PM, V5 CNA (Certified Nursing Assistant) said she was changing R1 on 12/29/24 when
she rolled out of bed and onto the floor. V5 said, I was on her left side and turned her onto her right side.
When I turned her she continued to roll out of the bed. I am not sure what happened. I'm not sure if I rolled
her too far . She was pretty much asleep when I was changing her After she fell she was saying 'ow ow, I'm
in pain' . I had taken care of the her previous night too. She was a difficult turn. She is listed as a one assist
but she doesn't help turn at all.
On 1/2/25 at 1:13 PM, V3 RN (Registered Nurse) said, I didn't witness anything until after she was on the
floor. I was told by the CNA that she was changing her and she rolled out of the bed. I got there and she
was sitting on the floor on the left side and she was bleeding. I assessed her and they hoyered her back up
into bed. Once I went in and reassessed her she was complaining of pain. I went and called 911 . I thought
it was ridiculous . when you turn them you make sure they are stable before you take your hands off of
them .
On 1/2/25 at 3:05 PM, V6 RN (Registered Nurse) said R1 is an extensive assist of one and sometimes two
assist depending on the day. V6 said R1 is definitely a difficult change (incontinence change) and it has
been getting harder since she has been declining. V6 said they have usually been using two people but
with agency staff she feels like they go and attempt care and don't get assistance until they realize how
difficult the resident is.
On 1/2/25 at 3:35 PM, V2 DON (Director of Nursing) said R1 was struggling with turning and rolling and
being able to assist with that. V2 said after R1's fall, they changed her to a two assist with incontinence care
and bed mobility.
The facility's policy with revision date of 8/1/23 showed, Fall Prevention Guideline . General: It
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145312
If continuation sheet
Page 2 of 3
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
01/02/2025
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)
F 0689
is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the
risk of falls and fall related injuries .
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's policy with revision date of 3/2024 showed, Falls Management . General: This facility is
committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all
falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative
strategies, and facility as safe an environment as possible .
Event ID:
Facility ID:
145312
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the January 2, 2025 survey of SYMPHONY NORTHWOODS?
This was a inspection survey of SYMPHONY NORTHWOODS on January 2, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SYMPHONY NORTHWOODS on January 2, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.