Inspection·October 2, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the coffee and V1 (Administrator) had her turn the machine down to 135 degrees F. V3 said prior to the resident getting burned the machine was set at 165 degrees F. V3 said after she turned it down to 135 degrees F the residents complained and so she turned it back up to 155 degrees F. V3 said she doesn't have a owner's manual for the hot water machine, she just Googled what temperature to set the machine to. V3 was not aware of what temperature to serve hot liquids at. V3 said when R1 got burned it was a Sunday, and she came in and temped the coffee but she didn't document it. V3 said there was no process change for making coffee after the incident and she did not start temping the coffee or hot water before serving. On 9/30/24 at 9:55 AM, V3 (Dietary Manager) poured hot water from the machine and temped the water. The thermometer read 146.9 degrees F. On 9/30/24 at 10:15 AM, V5 (Assistant Maintenance Director) with this surveyor, calibrated his thermometer with ice water and got a temperature of 33 degrees F. V5 then poured hot water from the hot water machine into a coffee cup (used to serve residents) and got a temperature of 143.2 degrees F. V5 said he is not aware of any problems with the hot water machine. On 9/30/24 at 11:05 AM, V6 (Licensed Practical Nurse/LPN) said on 9/15/24, R1 had coffee in an insulated metal to go cup that her family supplied and had spilled the coffee on her lap. V6 said V7 (Certified Nursing Assistant/CNA) had brought R1 from the dining room to the resident hallway outside of R1's room. V6 said she heard R1 yell it's burning! V6 said she had V15 (CNA) lay R1 down in bed to remove her pants. V6 said R1 had redness to her left inner thigh area. V6 said R1's family was at the facility and wanted R1 to get back up to her chair and go the the dining room. V6 said she notified V2 (Director of Nursing), V9 (Nurse Practitioner), and V11 (hospice nurse). V6 said she worked on R1's section for the morning shift and then worked in another section for the PM shift. V6 said V10 (LPN) (who was taking care of R1's section for the PM shift) called her over to look at R1's legs. V6 said both legs around the inner thigh were blistered. V6 said she didn't measure the burns at the time, but the left inner thigh was about the size of a softball and the right inner thigh had multiple blisters of all sizes from just below the groin down her thigh to about 4 inches above her knee. On 9/30/24 at 11:22 AM, V7 (CNA) said she had brought R1 back from the dining room to her hallway and R1 started pulling on her pants and yelling it's hot! V7 said at that time she noticed R1's pants were wet on her inner thighs. On 9/30/24 at 1:48 PM, V1 (Administrator) said when she was notified of R1's burns on 9/15/24, she had V3 (Dietary Manager) tell her the temperature that the hot water machine was set at, and had her lower it. V1 said she didn't have any one check temperatures of the hot water at that time or have had kitchen staff monitoring the temperatures of the hot water since. R1's most recent Care Plan shows R1 has diagnoses of spinal stenosis, unspecified dementia, Parkinson's disease with dyskinesia, and unspecified neuropathy of lower limbs. This same Care Plan shows R1 has severe impaired cognitive function related to dementia, has Parkinson's with tremors, neck contracture, and decreased safety awareness. R1's Progress Note dated 9/15/24 at 9:14 AM, by V6 (LPN) shows resident spilled coffee on her left leg, redness and irritation. R1's Wound Summary dated 9/16/24 by V8 (Wound LPN), shows right medial thigh, burn, 2nd degree, facility acquired, measuring 13.0 x 6.0 x 0.1 cm (centimeters). R1's Wound Summary dated 9/16/24 by V8 (continued on next page) 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 10/02/2024 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 0689 shows left medial thigh, burn, second degree, facility acquired, measuring 18.0 x 18.0 x 0.1 cm. Level of Harm - Immediate jeopardy to resident health or safety R1's Physician Wound Evaluation and Management Summary dated 9/18/24 (3 days after sustaining burns) shows: Burn of the left anterior thigh full thickness (3rd degree), etiology: hot liquid, wound size: 2.7 x 7.5 x 0.1 cm. Burn of the right medial thigh partial thickness (2nd degree), etiology: hot liquid, wound size: 7.5 x 6.0 x 0.1 cm. Burn of the left medial thigh, etiology hot liquid, wound size: 2.5 x 4.0 x not measurable cm, fluid filled blister. Residents Affected - Some The facility's undated Hot Beverage Policy shows hot beverages are provided to the clients in a safe manner. There is no specific temperature at which hot beverages should be served. Palatability versus the risk of scalding are factors the community takes into consideration when serving hot beverages. On 10/1/24 at 1:12 PM, V1 (Administrator) said she reached out to the kitchen provider for safe temperatures for serving hot liquid and the preferred temperature for consuming is 120-135 degrees F, which they will be implementing. 10/1/24 at 1:05 PM, V17 (Dietitian) said she didn't know the safe temperature range to serve hot beverages at, she would need to consult her manual. V17 said the kitchen should have a policy on temperatures, how to monitor temperatures and by whom. The Immediate Jeopardy that began on 9/15/24 was removed on 10/2/24 when the facility took the following actions to remove the immediacy: -Procedure developed and implemented to ensure safety with hot beverages, including checking and logging temperatures prior to the beverages leaving the kitchen and beverages not being served if they do not meet the appropriate temperature range of 120 F to 135 F. -Preferred temperature for consuming coffee/tea is 135 F =/- 15 F. (120 F to 135 F). Procedure includes acceptable temperature range. -100% of kitchen staff in-serviced on procedure to check hot beverage temperatures. Hot beverages are only prepared by kitchen staff. -100% of kitchen staff in-serviced on safe temperature range for consuming hot beverages. -Appropriate thermometer present in kitchen with ability to be calibrated. Temperature range 0 F to 220 F. -Four additional thermometers were ordered with the ability to be calibrated with a temperature range 0 F to 220 F to be delivered on 10/2/24. -The fifty residents currently residing in the facility that were identified to prefer hot beverages had screening completed to assess for safe handling of hot beverages. -The remaining twenty five residents in the facility that were not identified to prefer hot beverages will have screening completed to assess for safe handling of hot beverages in case of preference change. (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 10/02/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some -Effective 10/2/24, all residents will be screened by therapy/nursing using the Interdisciplinary therapy screening tool to determine safe handling of hot beverages. Diet order, diet tray card and individualized care plan will be updated accordingly. -Staff training to be 100% completed by 10/2/24. -Screening for safe handling of hot beverages audit tool to be completed by DON/designee: 3 x/wk [times per week] for 2 weeks, then 2 x/wk for 2 weeks then weekly times 2 weeks and results reviewed at QAPI [Quality Assurance and Performance Improvement] with Interdisciplinary Team (IDT) and Medical Director. -Hot beverage temperature audit tool to be completed by Dietary Manager/Administrator: 5 x/wk for 2 weeks, then 3 x/wk for 2 weeks then 2 x/wk for 2 weeks, then weekly times 2 weeks and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 4 of 4