Inspection·February 28, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to to provide ADL (Activities of Daily Living) assistance to residents that required assistance with toileting/incontinence care for 3 of 5 residents (R2, R5, R3) reviewed for ADLs in the sample of 5. Residents Affected - Few The findings include: 1. R2's current care plan showed R2 required the extensive assistance of staff for toileting and perineal cares due to her diagnosis of a stroke (CVA/cerebrovascular accident). The plan showed R2 was incontinent of urine. The care plan showed, Check as required for incontinence. On 2/28/24 at 8:19 AM, R2 was in bed, dressed in a nightgown. A strong odor of urine was noted from R2's side of the room. At 8:30 AM, V5 Certified Nursing Assistant (CNA) and V6 CNA approached R2 and began providing cares. V5 stated, We are getting a late start today getting everyone up. We only had one CNA on the unit last night. This is my first time doing cares on (R2). V5 stated she was unsure the last time R2 was provided with incontinence care, stating, sometime on night shift. V5 and V6 removed R2's incontinence brief. R2's brief was saturated with urine, turning the padding of the brief brown in color. R2 has a small amount of dried stool to both buttocks. R2's urinary incontinence monitoring and toileting records dated 2/27/24 showed R2 was last provided with incontinence care at midnight on 2/27/24. 2. R5's current care plans showed R5 required the assistance of staff for toileting due to her diagnosis of stroke. R5's resident assessment dated [DATE] showed R5 was always incontinent of urine. On 2/28/24, R5 was awake, in bed, dressed in a nightgown. V5 CNA entered R5's room. R5 stated, I'm ready to get up. V5 CNA stated to R5, Got a late start today. We are short-staffed. V5 CNA got R5 out of bed and took her into the bathroom. V5 removed R5's incontinence brief before setting R5 on the toilet. R5's brief was soiled with a large amount of urine. R5's inner buttocks were light pink in color. When R5 was asked when she was last toileted or provided with incontinence care, R5 stated, Some time late last night. R5's urinary incontinence monitoring and toileting records dated 2/27/24 showed R5 was last provided with incontinence care at 12:05 AM on 2/28/24. 3. R3's current care plan showed R3 required the extensive assistance of staff for toileting (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: 145990 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 145990 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Symphony Maple Crest 4452 Squaw Prairie Road 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)