Inspection·July 21, 2025

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 interview and record review the facility failed to put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) dated 5/21/25 states, Resident observed laying on the floor next to his bed on his right side. Resident tried to get self up from his bed and slid to the floor. No injuries noted, no pain or discomfort verbalized or demonstrated . Resident transferred back to bed .R1's Care Plan dated 12/17/24 states, Potential for falls, Resident at risk for injury from falls, history of falls. The intervention UA sent to rule out infection shows a date initiated as 5/23/2025. No other interventions were put in place to prevent R1 from falling after the fall on 5/21/25. An incident report dated 5/29/25 states, On 5/27/25 at approximately 6:40PM the resident was reported to have an unwitnessed fall in the resident's room when attempting to self transfer to the restroom. This same report states, On 5/28/25 the resident was noted to be complaining of mild-moderate pain to the right side. An X-ray was ordered and performed on 5/28/25. X-ray results showed acute appearing right lateral 8-11 rib fractures with displacement and mild soft tissue swelling. NP (Nurse Practitioner) updated with results and order was given to transfer resident to the ED (Emergency Department) for further evaluation and treatment. This report also states, The resident has a BIMS (Basic Interview for Mental Status) of 12 on 12/13/24 (mild cognitive impairment). At the time of the resident's fall, the resident stated he was attempting to walk to his bathroom .R1's Radiology Report dated 5/28/25 states, Acute appearing right rib fractures. R1's Hospital admission Report dated 5/28/25 states, He had a mechanical fall- tripped and fell- about 2 days ago. Hitting his right side chest. He was discovered to have 4 broken ribs 8-11. He was brought to the ED tonight for further evaluation. He is complaining of pain onto his lateral right chest and right back. He is having difficulty breathing .Upon arrival in the ED he was hypoxic at 89% on room air at rest. He was tachypneic. Blood pressure was borderline low. On 7/21/25 at 2:30PM V2 (Director of Nursing) stated, (R1) was more confused than normal on the 21st after his first fall. He was with it and could answer questions but something was just off. The (V6- Nurse Practitioner) ordered a UA (Urinalysis). I didn't talk to any of the family before that. We did the UA and we could have started antibiotics based on that but (V6) waited for the culture. The UA looked bad but some of the doctors wait for the culture- I think we should start the antibiotic and change it if we need to when the culture arrives. The UA was done to try to clear up some of the confusion to prevent falls. On the second fall on the 27th the granddaughter came in right after it and thought he was a little confused and I told her that is how he has been and then we sent him out the next day for the rib fractures. I remember he told me that some guys had come into his room and he had to chase them out and then he had to go to the parking lot to get his truck. V2 did not know of any other (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 07/21/2025 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)