Inspection·June 17, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse. This applies to 1 of 8 residents (R1) reviewed for abuse in the sample of 8. The findings include: The facility's reported incidents dated June 2, 2024 shows, resident abuse with R1 and V3 Certified Nursing Assistant (CNA). R1 is a [AGE] year-old male who resides at the facility for long term care services. He is alert and oriented with occasional forgetfulness and confusion. Diagnosis include, but not limited to: Diabetes, atrial fibrillation, dementia with psychotic disturbance, depression, CKD (chronic kidney disease) and congestive heart failure. On 6/2/24 at approx. (approximately) 2:40pm (2:40 PM), a staff member (V4 Registered Nurse (RN) reported to administrator that a CNA (V3) was observed telling R1 to shut up and go to his room. Findings: The facility conducted a thorough investigation pertaining to the allegation of abuse. Based on interviews with R1 and facility staff, including witnesses, the facility does substantiate verbal abuse. On June 17, 2024 at 11:30 AM, R1 was sitting up in his wheelchair in his room. He stated, sometimes the staff is in a mood but no one has been mean to him. He did not remember the incident on June 2, 2024. On June 17, 2024 at 9:59 AM, V4 RN stated, she was giving report to the second shift nurse when they heard some yelling. They paused their report and heard more yelling. They stepped out of the medication room and saw V3 CNA coming away from R1's room (right across from the nursing station) after she slammed his door. V4 RN stated, she told V3 CNA she could not yell at him like that or shut his door. R1 is a fall risk and to open the door back up. V3 CNA stated, well he needs to shut up. V4 RN said that was not right and reported the incident to V1 Administrator right away because you can't treat residents that way. On June 17, 2024 at 12:25 PM, V5 CNA stated, her statement has more details but from what she remembered, she was at the nurses station getting report from another CNA. She wasn't paying full attention but she heard V3 CNA tell R1 he needed to be quiet and pushed him into his room. R1 came back out of his room saying, don't push me and other comments. V3 CNA walked back and pushed him back in the room, told him to be quiet and slammed the door. At that point, the nurses came out and saw what was going on. I think he had gotten on her nerves. She stated, V3 CNA should have handled the situation differently. She also stated, she heard V3 CNA tell the nurse that R1 needed to shut up. V5's CNA statement dated June 2, 2024 shows, During report V3 CNA heard R1 speaking and she began (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 06/17/2024 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)