Inspection·April 22, 2024

F 0744 Level of Harm - Minimal harm or potential for actual harm water at (R1) because she kept coming into our room. He was trying to stop her. That day she had already tried to come in twice before. He was trying to keep her out of our room. She would try to come in our room all the time. She still tries to come into my room a couple of times a week. Staff are busy. She's hard to keep track of. I tell her to leave and she just looks at me. She won't leave until staff come in and take her out. I think she's confused. Residents Affected - Few On 4/22/24 at 11:00 AM, V4 Certified Nursing Assistant (CNA) stated, (R1) wanders all over the building, all the time. I would say she tries to wander into other resident's rooms multiple times a shift. She is very confused. We try to keep track of her. She is not on frequent checks that I know of. I was just told to watch her because she wanders. That day (4/11/24), (R1) kept trying to go into (R2's) room. I was sitting at the nurse's station. I saw (R1) rolling herself down the hallway. The next thing I know, I hear water hit the floor. I look up. (R1) is in (R2's) room, by the door, and her face is wet. (R2) was yelling, telling us to get her out of his room. (R2) was just trying to stop (R1) from coming more into his room. (R1) had no idea what was going on. I got up and immediately got her out of (R2's) room. V4 stated she was hired by the facility in February 2024 but had not received any dementia training since being hired. On 4/22/24 at 11:23 AM, V3 CNA stated she was hired by the facility on 4/1/24. V3 stated she had not received any dementia training during her employment at the facility. V3 stated, I know (R1) is a wanderer and we are supposed to watch her. She propels herself around the building. When we don't see her, we know we have to walk around the building and find her. On 4/22/24 at 9:43 AM, V7 CNA stated R1 tries to enter other resident rooms a lot. V7 CNA stated, (R1) is really confused. We try to watch her but she propels herself all over the building. It's hard to keep track of her. On 4/22/24 at 10:10 AM, V1 Administrator stated, On 4/11/24, (R2) was very frustrated because (R1) kept trying to come into his room. She had tried to come in one time before that day when (R2) had just gotten out of the shower. (R2) told me he threw the water to get her to stop coming into his room. He said he had previously yelled at her to get out and she didn't leave. (R2) was upset because he felt the staff knew (R1) kept trying to come into his room but staff weren't intervening . If a dementia resident is trying to go into other resident rooms, staff are to be checking on that resident's whereabouts every 15-30 minutes. The goal is to make sure we know where the resident is and redirect the resident to avoid any issues. The facility's Dementia policy dated 4/2024 showed, A resident who displays or is diagnosed with Dementia, receives the appropriate treatment and services to attain and maintain his or her highest practicable physical, mental, and psychosocial well-being . The facility's approach to care for a resident living with dementia follow a systemic care process to ensure that residents' individualized dementia care needs are met. The facility will assess, develop, and implement care plans through an interdisciplinary approach .Develop individualized interventions, related to the resident's symptomology and rate of progression . Modify the environment to accommodate resident care needs . The facility's Wandering policy dated 1/2024 showed, The staff will identify residents who are at risk for harm because of wandering behaviors . Interventions to try to maintain safety will be included in the resident's care plan . Staff will institute a care plan, as indicated for residents who are assessed to have a high risk of elopement/exit seeking/wandering . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 2 of 4 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 04/22/2024 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)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review the facility failed to ensure newly-hired nursing staff received dementia care training and education prior to caring for facility residents. This failure has the potential to affect all 73 residents in the facility. The findings include: The Facility Data Sheet dated 4/22/24 showed 73 residents resided in the facility. On 4/22/24 at 11:23 AM, V3 CNA stated she had received no dementia training or education during her employment at the facility. On 4/22/24 at 11:00 AM, V4 CNA stated she had received no dementia training or education during her employment at the facility. On 4/22/24 at 11:30 AM, the following employee files were reviewed with V9 Human Resources (HR); 1. V4 Certified Nursing Assistant's file (CNA) showed V4 was hired on 2/1/24. The file showed no documentation of V4 receiving dementia education or training from the facility. V4's April 2024 timecard showed V4 worked 4/11-4/14/24 and 4/17-4/19/24, providing cares to residents in the facility. 2. V7 CNA's file showed V7 was hired on 2/12/24. The file showed no documentation of V7 receiving dementia education or training from the facility. V7's April 2024 timecard showed V7 worked 4/11, 4/13,4/14, and 4/16-4/19/24, providing cares to residents in the facility. 3. V8 Licensed Practical Nurse/LPN's file showed V8 was hired on 2/19/24. The file showed no documentation of V8 receiving dementia education or training from the facility. V8's April 2024 timecard showed V8 worked 4/13-4/15/24 and 4/19/24, providing cares to residents in the facility. 4. V3 CNA's file showed V3 was hired 4/1/24. The file showed no documentation of V3 receiving dementia education or training from the facility. V3's April 2024 timecard showed V3 worked 4/11, 4/16, 4/18, 4/20, and 4/21/24, providing cares to residents in the facility. On 4/22/24 at 11:35 AM, V9 HR stated all newly hired staff receive dementia training during their orientation class, prior to providing resident cares. V9 HR stated V3 CNA, V4 CNA, V7 CNA, and V8 LPN had not received any dementia training upon hire to the facility because they haven't gone through orientation yet. We needed to get them on the floor as soon as possible to provide cares. On 4/22/24 at 11:29 AM, V2 Director of Nursing (DON) stated, Staff should have dementia training when hired and then annually. We do have nursing staff working the floor that haven't gone through orientation and haven't had the dementia training. When V2 DON was asked how she could ensure the facility's dementia residents are receiving the cares and monitoring they need if staff have not had the dementia training or education, V2 stated, I have only been in my role (DON) for three weeks. I can't speak to any staff that were hired before me. The facility's General Orientation Checklist and Acknowledgement forms (undated) showed Dementia care and resident Elopement education are provided to new staff during an orientation class. The forms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 3 of 4 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 04/22/2024 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)

F 0947 showed new staff receive education on the types of Dementia during orientation. Staff also receive education on how care for and communicate with a dementia resident during orientation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 4 of 4