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 provide showers to a resident that needs
assistance in activities of daily living (ADL) to 1 of 5 residents (R3) reviewed for ADL care in the sample of
5.
Residents Affected - Few
The findings include:
R3's facility assessment dated [DATE] show R3 has no cognitive impairment.
On 7/10/24 at 9:20 AM, R3 was sitting in her wheelchair in her room. R3 said her scalp was itching and said
she has not had a shower or her hair washed since 7/1/24 (Monday). R3 said her shower days are
Mondays and Thursdays. R3 said she did not have a shower last July 4 (she would remember since it was
a holiday.) R3 said she did not receive any shower last Monday (July 8). R3 stated I better have a shower
tomorrow! The running water is refreshing to me. R3 said what she had done was to wash up in her sink but
she was looking forward to her shower and her hair wash tomorrow.
On 7/10/24 at 12:00 PM, V2 (Director of Nursing-DON) said she had updated all the residents shower
schedules. V2 (DON) confirmed R3's shower days are Mondays and Thursday per facility tasks. V2 said all
residents should receive their shower per their schedule for hygiene purposes. V2 said she will make sure
R3 will receive her shower today.
R3's careplan dated 12/12/23 shows, (R3) has ADL self care performance deficit and will maintain current
level of function: Bathing- requires staff participation. Personal Hygiene-requires assistance with personal
hygiene care.
The facility ADL policy dated 11/2023 shows, A Hygiene, a. self image is maintained. f. Showers or baths
will be scheduled per facility protocol while incorporating residents preferences.
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
07/10/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide incontinence care in a manner to
prevent infection to 1 of 5 residents (R2) reviewed for incontinence care in the sample of 5.
The findings include:
R2's Facility assessment dated [DATE] show R2 has no cognitive impairment and R2 is incontinent of
bladder
function.
R2's medical record show R2 has history of urinary tract infections (UTI).
On 7/10/24 at 8:30 AM, R2 was in his room doorway sitting in his wheelchair with strong urine odor. This
surveyor requested for skin check. R2 was placed in bed. V4 (Certified Nursing Assistant-CNA) removed
incontinent brief soiled with urine. V4 (CNA) took incontinent wipes and wiped R2's frontal area then
applied new incontinent brief. V4 did not cleanse or provide incontinence care to buttocks or thigh area to
R2.
On 7/10/24 at 9:35 AM, V5 (Licensed Practical Nurse-LPN) said residents should be provided thorough
incontinence care including their back area, buttocks and thighs to prevent skin breakdown since R2 now
has skin irritations and redness. Incontinence care also provides comfort and prevents infection.
R2's careplan dated 6/28/24 shows, R2 has bladder incontinence, R2 will remain free from skin breakdown
due to incontinence and brief use through the review date with intervention to include: Check as required
for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.
The facility policy on Incontinence Care dated 11/2023 shows, Incontinence care is provided to keep
residents as dry, comfortable and odor free as possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145990
If continuation sheet
Page 2 of 2
