Inspection·November 4, 2024

F 0689 Level of Harm - Actual harm Residents Affected - Few of the bed and she was next to R1 getting the wheelchair in position. V4 said R1 tried to stand by himself and his right hand reached for the wheelchair which moved (was not locked due to not in position yet) and R1 fell forward onto the floor on his right side. V4 said R1 kept saying ouch, but was moving around on the floor. V4 said she sent V5 to get the nurse. V4 said R1 didn't have a gait belt on, the plan was to hold R1 by the pants to transfer him. On [DATE], V5 was attempted to be reached via phone two times and messages left, with no return call. The facility's Incident Staff Statement from V5 shows R1 stood up with pants down without support, slipped on pants and fell criss-cross on his right leg. I heard him scream ow my leg repeatedly. R1's Progress Note dated [DATE] shows called to room by CNA and observed resident sitting on the floor with legs crossed under the bed facing the doorway. Resident was attempting to get up form floor independently and would not follow request to wait until assessment was completed. When asked what happened resident stated, I fell. Assist resident into bed, assessment completed, noted external rotation, shortening, and deformity noted to upper right leg no other injuries observed. On [DATE] at 10:01 AM, V2 Assistant Director of Nursing said R1 had poor safety awareness, was cognitively impaired, and was impulsive. V2 said R1 transferred via stand pivot with one assist to the wheelchair. V2 said staff are supposed to use a gait belt for transfers per the facility policy and for safety. V2 said the gait belt helps with stability and helps staff have some control during the transfer and staff can hold the gait belt to lower the resident to the floor during a fall. V2 said after speaking with the staff, R1 was sitting at the bedside and before staff was able to assist, R1 attempted to stand but has his legs crossed and fell to the right onto the floor. V2 said at the time, R1 did not have a gait belt on. On [DATE] at 2:05 PM, V10 Nurse Practitioner said R1 had progressing dementia and was on hospice at the time of his fall. V10 said resident's Care Plans and facility policy should be followed when transferring residents. R1's Fall Risk Screen dated [DATE] shows R1 is at high risk for falls due to history of multiple falls and R1 exhibits loss of balance while standing. R1's Hospital After Visit Summary shows R1 has a periprosthetic fracture of proximal end of right femur. R1's Care Plan shows R1 is at risk for injury from falls related to unsteady gait, reduced strength, poor decision making related to dementia. The same Care Plan shows R1 is a restorative program for ambulation with interventions to give verbal cues and assistance to don gait belt, stand upright and avoid leaning, and stand using a wide support base. The facility's undated Safe Resident Policy shows Gait belt usage is mandatory for all residents handling with the exception of bed mobility and medical contraindications. 2. On [DATE] at 12:10 PM, R2 was sitting at the dining room table with her husband V11. R2 had visible blood crusted sutures along her hair line extending from the middle toward the right side. R2 had yellowish colored bruising on her right to middle forehead and some purple/red colored bruising under her right eye. R2's left arm was in a brace. V11 said R2 has 21 sutures from her fall on [DATE]. (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 11/04/2024 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 - Actual harm Residents Affected - Few R2 nodded and touched her hairline and continued eating. V11 said that day it was so windy, there was 50 mph wind gusts and R2 had a doctor appointment. V11 said they were coming down the sidewalk of the facility to the van and there is a slope in the sidewalk after going around the flagpole to go down to get to the ramp of the van. V11 said the slope of the sidewalk made the wheelchair lean forward a bit and R2 fell forward out of the wheelchair onto the ramp of the van. V11 said he was at the back of the wheelchair and there was the van driver trying to get R2's wheelchair down the slope of the sidewalk and onto the ramp. V11 said the sidewalk goes around the flag pole area and then slopes down sharply to meet the sloped area of the sidewalk going into the drive. V11 said there are better areas of the sidewalk to load a wheelchair from where the slope is less steep and you don't have to maneuver around the flagpole. V11 said there was only one staff member and himself trying to get R2 onto the van. On [DATE] at 12:18 PM, this surveyor observed the facility sidewalk leading from the entrance to the driveway of facility. The sidewalk from the facility entrance leads perpendicular to the driveway. There is a sidewalk that runs along side the driveway and intersects with the entrance sidewalk. At the intersection there is a triangular flower bed with a flag pole in the center. In order to reach the sloped area from the sidewalk into the driveway, you have to walk around the flag pole area and go down a sharp incline to then reach the sloped area of the sidewalk going down to the driveway. A wheelchair would have to go left or right around the flag pole, propel forward (parallel to the driveway) go down the sharp incline, then turn perpendicular to the driveway to go down the slope in the sidewalk that connects with the driveway. On [DATE] at 10:01 AM, V2 Assistant Director of Nursing said she was in the administrators office by the facility entrance when staff came and told her a resident had fallen outside. V2 said she ran outside and found R2 on the ground with her face on the wheelchair ramp of the transport van. V2 said V11 told her R2 had leaned forward and fell out of the wheelchair. V2 said she could see blood pooling but could not tell where it was coming from and didn't want R2 to move. V2 said V10 Nurse Practitioner had also come outside and was helping stabilize R2's head and hold pressure. V2 said it was extremely windy and started to pour down rain on them. V2 said V11 was propelling R2 in the wheelchair up until V7 Activity Aid took over at some point. V2 said there is a dip in the sidewalk leading to the slope of sidewalk where the wheelchair lift of the van was. On [DATE] at 12:26 PM, V7 said she is the driver of the van that takes residents to appointments. V7 said she is an activity aid and is not a CNA. V7 said V11 pushed R2 in her wheelchair from the front door, down the sidewalk, around the flag pole and down the sidewalk incline to the sloped area of the sidewalk leading to the driveway. V7 said she took over pushing R2 and then R2 leaned forward and fell out of the wheelchair. V7 said it was very windy that day and almost immediately started pouring when R2 fell. V7 said there was no other staff that assisted her that day. V7 said she should have asked someone to come along since it was so windy. V7 said R2 did not have any foot pedals on her wheelchair and had her left arm in a brace so was not able to stop herself when she was falling forward. On [DATE] at 1:12 PM, V8 Restorative Aid said R2's left arm is broken and is in a brace so R2 can't propel herself and can't stand without staff assistance. V8 said she issues foot pedals to all new residents. V8 said R2 should have had foot pedals on since R2 can't propel or stabilize herself in the wheelchair. V8 said she got R2 up for the day and took her to therapy. V8 said she didn't put foot pedals on R2's wheelchair at that time. V8 said after therapy, R2 went to breakfast and then was leaving to go to a doctors appointment. V8 said she was not R2's CNA that day, and had just helped by getting her up that morning. V8 said she was not sure if R2 left for the appointment with her foot (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 11/04/2024 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 pedals on the wheelchair. Level of Harm - Actual harm On [DATE] at 1:15 PM, V9 Nurse Practitioner said R2 is so fearful of falling and is not able to stand for any significant amount of time. V9 said R2 had Parkinson's and has an elbow fracture from a fall at home. V9 said R2's left arm is in a brace and R2 has generalized weakness and unsteadiness due to Parkinson's V9 said R2 has no ability to stop herself from falling forward from the wheelchair. Residents Affected - Few On [DATE] at 1:32 PM, R2 was sitting up in her wheelchair in her room, there were no foot pedals on her wheelchair. R2 said when she fell, she was going downhill and leaned forward and couldn't stop herself from falling since her left arm was in a brace. R2 said she didn't have foot pedals on her wheelchair. R2's Hospital After Visit Summary dated [DATE] shows 7 sutures place in [NAME] (layer of scalp) and 14 sutures placed superficially. The facility's Fall Report dated [DATE] shows V7 statement I was transporting R2 to her doctor appointment today. It was approximately 10:20 AM. I was pulling the bus to the front door and R2 and V11 were waiting at the front door to come out the bus. I pulled up and and V11 started pushing R2 down the sidewalk towards the bus and when he got R2's wheelchair to the edge of the sidewalk/start of the wheelchair lift I was trying to turn R2's wheelchair so that I could put her wheelchair on the lift, but it was extremely windy causing problems turning R2 and V11 was in a rush to get her to her appointment. I went to push her onto the wheelchair ramp and she tipped forward and fell forward onto the ramp. I told V11 to get someone right away in the building. R2's Care Plan shows R2 has diagnoses of muscle weakness (generalized), unsteadiness on feet, difficulty walking, Parkinson's disease with dyskinesia with fluctuations and injury of left elbow. The same Care Plan shows R2 has a hinged brace to her left arm related to a fracture, demonstrates a self-care deficit and requires assist with activities of daily living related to limited mobility and impaired balance, non-weight bearing to left upper extremity, needs assist of 2 for transfers. The Care Plan shows R2 has potential for falls and is at risk for injury from falls. The same Care Plan was updated after R2's fall on [DATE] with the intervention staff to ensure resident foot pedals are on wheelchair prior to propelling resident, Ensure resident positioned properly in wheelchair. R2's Occupational Therapy Evaluation and Plan of Treatment dated [DATE] shows R2 has impaired range of motion to her upper extremities and R2's sitting balance during activities of daily living is fair (reach to ipsilateral side and unable to weight shift). Clinical Impressions: Patient presents with reduced functional activity tolerance, balance and strength affecting safety, ease and independence with activities of daily living and functional mobility. Risk factors: Due to the documented physical impairments and associated functional deficits the patient is at risk for falls, further decline in function and increase dependency upon caregivers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 4 of 4