Inspection·June 11, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility to ensure a resident with acute delusions was monitored and supervised. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including unspecified psychosis, cerebral infarction, hypertension, adjustment disorder with depressed mood, weakness and unsteadiness on feet. R1's face sheet shows she was admitted to the facility on [DATE] from the hospital. On 6/11/25 at 9:57 AM, R2 (R1's roommate) said on Friday night (6/6/25), R1 woke up screaming after the nurse woke her up to give her medications. R1 was screaming your not my nurse, your not my nurse. R1 also alleged the nurse put something on her wrist and was hurting her (blood pressure cuff). R1 kept yelling and finally a male nurse came in V3 (Assistant Director of Nursing-ADON) and tried to calm her down. R1 was looking out the window yelling to call 911, and yelling out for Michael call 911. R2 said V3 sat in the room for a while until R1 calmed down. She said she did not witness any staff hurt R1. R2 said this was the 2nd night in a row she could not sleep because of R1 was not right during the night. R1 was fine during the day, we would talk, but during the night she was not right, not humane. Maybe she was sundowning, she was confused and a different person during the night. On 6/11/25 at 11:31 AM, V3 (ADON) said he came in to cover the first half of the 3rd shift due to a call off. He said sometime after 12:00 AM, he heard yelling from R1's room. R1 was picking up the blinds saying her husband (V7) was outside. There was a car outside, but it was not her husband. V3 said he encouraged R1 to go back to sleep. R1 was alert and oriented and he thought maybe she was not getting enough rest. On 6/11/25 at 11:11 AM, V4 (RN) said she came in at 2:00 AM to 6:00 AM and split the shift with V3. It was reported, R1 had behaviors of agitation but was re-directable. R1 was awake when she started her shift. R1 was placed at the nurses station so she could be supervised about 2:30-3:00 AM. R1 was pleasant when she was at the nurses station. She saw R1 last around 4:45 AM to 5:00 AM at the front lobby near the nurses station. Around 5:15 AM, V5 (Certified Nursing Assistant-CNA) came up to me if I had seen R1. She told V5 to check all the rooms and the basement and V6 (CNA) checked the rooms upstairs. V4 said she went outside to look for her and did not see her. She went back in the building and V5 and V6 reported they did not locate R1. V4 said she went back outside to the end of the driveway and saw R1 in her wheelchair down the street on the sidewalk. She assisted R1 back to the building, notified the POA and V2 (Director of Nursing). R1 told her she was trying to leave because she did not want to be at the facility anymore and reported an allegation of abuse. She said she was (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 06/11/2025 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)