Health inspection·November 20, 2024

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 Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that require staff assistance for incontinence care/toileting for 3 of 16 residents (R21, R1, R40) reviewed for ADLs in the sample of 16. Residents Affected - Few The findings include: 1. R21's current care plan showed R21 required the extensive assistance of staff for toileting, transferring and repositioning. The care plan showed R21 was incontinent of urine and stool. On 11/18/24 at 9:07 AM, R21 was asleep in her wheelchair in her room. On 11/18/24 at 10:36 AM, R21 remained seated in her wheelchair. R21 stated, I have to pee. No one has come. On 11/18/24 at 11:40 AM, V5 (Certified Nursing Assistant/CNA) and V7(CNA) transferred R21 into bed from her wheelchair. The pad on the seat of R21's wheelchair was wet with urine. The groin area of R21's pants was wet with urine. V5 and V7 removed R21's saturated incontinence brief. V7 (CNA) stated she had last changed R21's incontinence brief at 7:00 AM that morning. 2. R1's current care plan showed R1's is completely dependent on staff for repositioning and toileting/incontinence care. The care plan showed R1 was incontinent. On 11/18/24 at 9:30 AM, R1 was asleep in a high-back wheelchair. On 11/18/24 at 10:05 AM, R1 remained asleep in her wheelchair. An odor of urine was noted in R1's room. On 11/18/24 at 10:10 AM, V7 (CNA) stated R1's incontinence brief was last changed at 7:00 AM. On 11/18/24 at 11:29 AM, V7 (CNA) and V5 (CNA) transferred R1 into bed from her wheelchair. V7 and V5 repositioned R1 in bed and removed R1's incontinence brief. R1's brief was saturated with urine. R1's buttocks appeared red. 3. R40's current care plan showed R40 required the extensive assistance of staff for toileting and repositioning. The care plan showed R40 was incontinent of urine and stool. On 11/18/24 at 9:30 AM, R40 was seated in his wheelchair by the nurses station. On 11/18/24 a 10:00 AM, R40 remained seated in his wheelchair. Facility staff wheeled R40 into the main dining room for an activity. On 11/18/24 at 10:32 AM, R40 remained in the activity. On 11/18/24 at 11:06 AM, V4 (CNA) wheeled R40 into the bathroom and transferred him to the toilet. V4 removed R40's incontinence brief which was saturated with urine. R40's buttocks and groin were bright red in color. V4 stated she had last toileted R40 at 7:30 AM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 2 of 14 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 11/20/2024 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 0677 On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated, All residents should be checked and changed for incontinence care every 2 hours. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 3 of 14 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 11/20/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm 2. On 11/18/24 at 10:15 AM, R31 was in bed with his heels on the mattress. R31's heel boots were laying at the foot of the bed. Residents Affected - Few R31's Physician Wound Evaluation Summary dated 11/15/24 shows R31 has a Stage 3 Pressure Wound of the right heel with recommendations to float heels in bed: off-load wound. On 11/20/24 at 09:25 AM, V14 (Wound Registered Nurse) said R31 has a pressure ulcer on his right heel that is almost healed. V14 said R31 should have heel boots on both feet when in bed and on the right heel when up in the chair. V14 said R31's heels should be offloaded with the heel boots or pillows so the heels are not touching the mattress to reduce pressure on the heels. The facility's Skin Management Program dated 7/24 shows Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed,and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Appropriate preventative measures will be implemented on resident identified at risk (a score of 18 or less on the Braden Scale) and the interventions documented on the care plan. Based on observation, interview and record review the facility failed to complete weekly wound assessments on a resident's pressure injury. The facility failed to ensure pressure treatments and pressure relieving interventions were in place. These failures apply to 2 of 5 residents (R36, R31) reviewed for pressure injuries in the sample of 16. The findings include: 1. R36's current care plan showed R36 was at risk for impaired skin integrity related to her history of pressure injuries and diagnoses of decreased mobility, incontinence, and dementia. The care plan showed R36 had been under hospice care since October 2023. R36's Wound Assessment reports dated 9/4/24-11/15/24 were reviewed. R36's report dated 9/4/24 showed R36 had developed a new unstageable pressure injury to her sacral area measuring 2 cm (centimeters) x 1.5 cm x 0.1 cm. The report showed only one weekly wound assessment was completed on R36's pressure injury in October 2024. R36's physician order dated 9/6/24 showed R36's sacral pressure injury was to be cleansed with Dakin's solution (wound antiseptic) with Thera Honey (wound healing crème) applied to the wound bed, and covered with a gauze dressing, every Monday, Wednesday, Friday and PRN (as needed). On 11/18/24 at 10:55 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. R36's sacrum appeared red with a dime-sized open area noted to the sacrum. A small amount of dried blood was noted to the wound. V4 and V5 placed R36 in a clean brief. On 11/19/24 at 9:10 AM, V4 and V5 again provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. V4 and V5 cleansed R36 and placed R36 in a clean incontinence brief. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated, Pressure injuries are to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 4 of 14 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 11/20/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete assessed and measured weekly until healed. I can tell you weekly measurements were not done on (R36). My wound nurse left and my DON (Director of Nursing) walked out in October (2024). (R36's) wound should be covered with a dressing. If staff see there isn't one, they need to tell the nurse to make sure one is put on. The facility's Skin Management Program policy dated July 2024 showed, Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes . Residents with pressure injury will be assessed, measured, and staged weekly in accordance with practice guidelines until healed . Event ID: Facility ID: 145990 If continuation sheet Page 5 of 14 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 11/20/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure a resident, with a history of significant weight loss, received weight loss interventions as ordered. The facility failed to monitor this resident's weights as directed by the dietician. These failures apply to 1 of 3 residents (R21) reviewed for weight loss in the sample of 16. Residents Affected - Few The findings include: R21's Dietician assessment dated [DATE] showed R21 was at risk for malnutrition related to her diagnoses of dementia and dysphagia. R21's Weights and Vitals Summary showed R21 weighed 126.4 pounds (lbs) on 5/1/24 and dropped to 117.2 lbs on 6/4/24. This showed R21 sustained 7.28 % (9.2 lbs) in one month. R21's nutrition note dated 6/18/24 showed R21 was evaluated by V9 (Registered Dietitian/RD) for significant weight loss. The notes showed R21 was to receive supercereal at breakfast due to weight loss. The note showed V9 (RD) requested for R21 to be weighed, once a week, for the next four weeks, to monitor R21's weights. R21's Weights and Vitals Summary showed no documented weekly weights for R21 from 6/6/24-7/1/24. R21's weights for August 2024-November 2024 showed R21 maintained weights between 116-117 lbs. On 11/19/24 at 8:03 AM, R21 was seated in the main dining room of the facility eating breakfast. On R21's tray was a serving of pureed eggs and oatmeal. No pureed bread or supercereal was noted on R21's tray. V8 (Dietary Manager) was asked if R21 was served supercereal with breakfast. V8 stated R21 did not receive supercereal with breakfast. V8 looked at R21's meal ticket and stated, Does she get supercereal? R21's breakfast meal ticket dated 11/19/24 showed R21 was to receive supercereal and pureed bread with breakfast. On 11/19/24 at 10:37 AM, V9 (RD) stated she evaluated R21 on 6/18/24 after she had sustained a significant weight loss. V9 stated, I recommended she be weighed weekly for the next four weeks to monitor her weights and to make sure her weights were accurate. I see they were never done. She is to get supercereal at breakfast for her weight loss; to add increased calorie and protein to her diet. The facility's Communication of Weight Concerns policy dated July 2017 showed, Identified concerns with a change in weight will be recorded and reported in accordance with this policy . In the event of a 5% weight loss or weight gain, the guest will be re-weighed on the same scale to verify the weight change . If the re-weigh verifies a 5% weight loss or 5% weight gain, the nurse will notify the physician and the RD (Registered Nurse) . After evaluating the guest, the RD/CDM (Certified Dietary Manager) will initiate the appropriate interventions and update the guest's care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 6 of 14 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 11/20/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure oxygen was administered by the nurse, failed to have orders for oxygen, and failed to change oxygen tubing in order to prevent infection for 2 of 4 residents (R116, R31) reviewed for oxygen in the sample of 16. Residents Affected - Few The findings include: 1. On 11/18/24 at 9:26 AM, V12 (Certified Nursing Assistant) and V11 (Restorative Aid) were attempting to take R116 to the bathroom in the hallway. R116 was wearing a nasal canula connected to an oxygen concentrator, set at 2 liters. V12 went and got a portable oxygen tank to hang on the back of R116's wheelchair. V11 connected R116's nasal canula to the oxygen tank, turned the tank on, and set the dial to 2 liters. On 11/19/24 at 12:13 PM, V2 (Director of Nursing) said only nurses should administer oxygen and set the dial to liters per the physician order, including setting up portable oxygen tank. On 11/20/24 at 11:00 AM, V2 said there should be physician orders for residents on oxygen that have the number of liters the resident should be receiving. V2 said R116 is on oxygen, but there is no physician order currently entered. R116's Physician Order dated 11/20/24 shows, Oxygen 2 Liters Nasal Canula to maintain SPO2 >90% every shift for COPD. 2. On 11/18/24 at 10:15 AM, R31 was in bed wearing a nasal canula. R31's oxygen tubing was dated 11/4/24. On 11/19/24 at 8:17 AM, R31 was sitting up in his wheelchair with his oxygen on. R31's oxygen tubing was dated 11/4/24. R31 said he uses his oxygen all the time. On 11/19/24 at 9:48 AM, V3 (Assistant Director of Nursing) said oxygen tubing should be changed weekly and as needed. R31's Physician Orders dated 10/27/24 shows an order change oxygen tubing weekly as needed. The facility's Oxygen Administration dated 8/2024 The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. The oxygen delivery device will be changed once a week or as needed. The tubing will be dated to assist with tracking of when tubing should be changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 7 of 14 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 11/20/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview, and record review the facility failed to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility, this failure has the potential to affect all 64 residents in the facility. The facility's 671 Application for Medicare and Medicaid dated 11/18/2024 shows, 64 residents in the facility and a Medication Administration error rate of 31.25 percent. The findings include: 1. On 11/19/24 at 9:55 AM, R29 said, I waited 2.5 hours to get help changing my incontinent brief. (R45) was watching the clock to confirm how long it took. The afternoon shift and the weekend shifts are the hardest on the residents. On 11/20/24 at 8:25 AM, R29 said, The other night (11/18/24 evening shift) when I was lying in bed incontinent of urine and stool, I felt like the facility kind of forgotten us. I need help. I need help getting out of bed and into bed. I need help moving around in bed. I wish I could do it on my own. On 11/20/24 at 8:26 AM, R45 said, On Monday evening (11/18/24) (R29) waited from 6:30 PM, to 9:00 PM, to get help. Last night (11/19), again at 6:25 PM, (R29) asked for help, it took 2 hours to get help. She had wounds. The wounds could come back. It's not comfortable for me when (R29) is incontinent of stool and has to lay like that. I am independent, I do not get any help. I have fallen eight times; I use the bed rail and the arm of the wheelchair to transfer. If I did not have the bed rail I could not move. 2. On 11/19/24 at 9:50 AM, R17 (Resident Council President), R28, R29, R45, R60, and the Ombudsmen attended the Resident Council Meeting. On 11/19/24 at 9:55 AM, R28 said, We've had call lights on, and the CNAs (Certified Nursing Assistants) are always on their cell phones or talking at the nurses' station. The cell phones seem to be the issue. The facility has rules of no phones on the floor. I would think they could put their phones in their lockers. I think the staff should keep moving and not be playing on their phones when they should be giving us help. We need more staff and the staff we do have need to stay off their phones. It would help stop people from falling. Resident Council meeting minutes dated 10/09/2024 shows, Nursing: Customer Services concerns and concerns about cell phone usage. 3. On 11/19/24 at 10:00 AM, R17, R28, R29, R45, and R60 agreed they are not offered snacks. On 11/19/24 at 10:01 AM, R45 said, We use to get snacks. R29 said, We must get our own snacks. One of the resident's family members just brought snacks for us. (R45) and I will have to ration it for the next few days. On 11/19/24 at 10:57 AM, V8 (Dietary Manager) said, In the evening, to ensure the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 8 of 14 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 11/20/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dietary needs are met and compliance with their dietary order, I send down multiple types of snacks. Pudding or sweetened/flavored gelatin for puree and cookies for general texture diets. I provide them to the nurse on the floor. The nursing staff distribute the snacks to the residents. On 11/19/24 at 9:50 AM, R17, R28, R29, R45, and R60 agreed there are not enough CNAs on the evening shift. The facility's Nourishments (Night-Time Snacks) policy dated 2021 shows, Nursing will distribute the bedtime nourishments. 4. R1, R21, R36, and R40 are dependent upon staff for ADL's (Activities of Daily Living) including toileting. On 11/18/24 at 10:10 AM, V7 (CNA) stated R1's incontinence brief was last changed at 7:00 AM. On 11/18/24 at 11:29 AM, V7 (CNA) and V5 (CNA) transferred R1 into bed from her wheelchair. V7 and V5 repositioned R1 in bed and removed R1's incontinence brief. R1's brief was saturated with urine. R1's buttocks appeared red. On 11/18/24 at 11:40 AM, V5 (CNA) and V7 (CNA) transferred R21 into bed from her wheelchair. The pad on the seat of R21's wheelchair was wet with urine. The groin area of R21's pants was wet with urine. V5 and V7 removed R21's saturated incontinence brief. V7 stated she had last changed R21's incontinence brief at 7:00 AM that morning. On 11/18/24 at 11:06 AM, V4 (CNA) wheeled R40 into the bathroom and transferred him to the toilet. V4 removed R40's incontinence brief which was saturated with urine. R40's buttocks and groin were bright red in color. V4 stated she had last toileted R40 at 7:30 AM. R36's Wound Assessment reports dated 9/4/24-11/15/24 were reviewed. R36's report dated 9/4/24 showed R36 had developed a new unstageable pressure injury to her sacral area measuring 2 cm (centimeters) x 1.5 cm x 0.1 cm. The report showed only one weekly wound assessment was completed on R36's pressure injury in October 2024. R36's physician order dated 9/6/24 showed R36's sacral pressure injury was to be cleansed with Dakin's solution (wound antiseptic) with Thera Honey (wound healing crème) applied to the wound bed, and covered with a gauze dressing, every Monday, Wednesday, Friday and PRN (as needed). On 11/18/24 at 10:55 AM, V4 (CNA) and V5 (CNA) provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. R36's sacrum appeared red with a dime-sized open area noted to the sacrum. A small amount of dried blood was noted to the wound. V4 and V5 placed R36 in a clean brief. On 11/19/24 at 9:10 AM, V4 and V5 again provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. V4 and V5 cleansed R36 and placed R36 in a clean incontinence brief. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated, Pressure injuries are to be assessed and measured weekly until healed. I can tell you weekly measurements were not done on (R36). My wound nurse left and my DON (Director of Nursing) walked out in October (2024). (R36's) wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 9 of 14 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 11/20/2024 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many should be covered with a dressing. If staff see there isn't one, they need to tell the nurse to make sure one is put on. 5. On 11/18/24 at 9:59 AM, R60, R117's and R11's 8:00 AM medications were not provided on time due to their nurse needing to attend to another resident. This resulted in a 31.25 percent medication error rate due to late medications. 6. The facility's PBJ-Payroll Based Journal Staffing Data Report dated April 1 to June 30 2024 shows, One Star Staffing Rating was triggered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 10 of 14 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 11/20/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm 2.On 11/18/24 V13 (LPN) provided medications to R117 at 9:59 AM, and R11 at 10:05 AM. R117's and R11's EMAR (Electronic Medication Administration Record) administration tabs were colored red. Residents Affected - Few R117 was provided aspirin 81 mg, bupropion 150 mg twice a day, losartan 50 mg, multivitamin, potassium chloride 20 milliequivalents twice a day, prednisone 10 mg 2 tablets daily for three days, rivaroxaban 15 mg twice a day. R11 was provided a physician ordered dietary protein twice a day, aspirin 81 mg, ciprofloxacin (antibiotic) 500 mg twice a day, diltelazem 120 mg, methimazole 5 mg twice a day, vitamin C 500 mg twice a day, multivitamin. R11's blood pressure was 148/63. On 11/18/24 at 9:59 AM, V13 (LPN) was asked why R117 and R11's EMAR tabs are red. V13 said, I am late passing medication. I was attending to a resident that passed away this morning. The facility's Medication Pass Times provided 11/18/2024 by V1 (Administrator) shows medication pass times of : 6:00 AM, 8:00 AM, Noon, 2:00 PM, 4:00 PM, 6:00 PM, and 8:00 PM. Based on observation, interview and record review the facility failed to administer medications as ordered. There were 32 opportunities with 10 errors resulting in a 31.25% error rate. This failure applies to 3 of 4 residents (R60, R11, R117) observed in the medication pass. The findings include: 1. R60's admission Record dated 9/15/23 showed R60 had diagnoses of atrial fibrillation, congestive heart failure, hypertension and macular degeneration. R60's November 2024 Medication Administration Record showed the following physician orders: Calcium-Vitamin D Tablet 660/400 mg (milligram) tablet; give one tablet twice a day at 8 AM and 4 PM. Carvedilol 12.5 mg tablet; give one tablet twice a day at 8 AM and 4 PM. PreserVision/Lutein Oral Capsule; give one tablet twice a day at 8 AM and 4 PM. Tramadol 50 mg tablet; give one tablet twice a day at 8 AM and 4 PM. Tylenol Extra Strength 500 mg tablet; give one tablet twice a day at 8 AM and 4 PM. On 11/18/24 at 9:46 AM, V6 (Licensed Practical Nurse/LPN) administered one tablet (each) of Carvedilol, Calcium/Vitamin D, PreserVision, Tramadol, and Tylenol to R60. V6 (LPN) stated, I am running late with med pass today. These are 8 AM meds (medications). I am still trying to learn these residents. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated, Med administration is considered late if the med is given one hour or more after the time it is prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 11 of 14 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 11/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure opened, multi-dose insulin bottles and insulin pens were labeled with expiration dates for 4 of 4 residents (R3, R1, R29, R169) reviewed for medication storage in the sample of 16. The findings include: R3's physician order dated 10/25/24 showed R3 received 26 units of Lantus insulin, subcutaneously once a day. R1's physician order dated 5/23/23 showed R1 received 10 units of Aspart insulin, subcutaneously twice a day. R29's physician order dated 8/21/24 showed R29 received 40 units of Lantus insulin, subcutaneously once a day. R169's physician order dated 10/11/24 showed R169 received 6 units of Lispro insulin, subcutaneously three times a day. On 11/18/24 at 9:55 AM, the facility's 100 wing medication cart was reviewed with V6 (Licensed Practical Nurse/LPN). The following medication insulin pens/bottles were found opened with no expiration dates: one (1) Lantus insulin pen for R3, one Aspart insulin pen for R1, one bottle of Lantus insulin for R29, and one Lispro insulin pen for R169. V6 (LPN) stated all insulin bottles/pens must be dated when opened to know when the medication will expire. V6 stated, Most insulin expires 28 days after opened. The facility's Medication Storage in the Facility policy dated November 2021 showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Certain medications or package types, such as IV solutions, multiple dose injectable vials, certain ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency . The nurse shall place a date opened sticker on the medication and enter the date opened and the new expiration date, if applicable. Examples of medications with shortened expiration dates include insulins and inhalers . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 12 of 14 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 11/20/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to wear Personal Protective Equipment (PPE) in a contact isolation room, failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure injury, and failed to change gloves during incontinence care in a manner to prevent cross contamination. This failure applies to 4 of 4 residents (R116, R36, R39, R57) reviewed for infection control. Residents Affected - Some The findings include: The Resident Census and Condition Form (CMS 671) shows there are 64 residents residing in the facility. 1. On 11/18/24 9:26 AM, R116 was sitting in her wheelchair in her room. There was a contact isolation sign on R116's door. V12 (Certified Nursing Assistant/CNA) entered the room without donning PPE and stood at R116's side. R116 said she needed to go to the bathroom and needed her pants changed due to being incontinent. V12 asked R116 how she transferred and R116 said this was her first time up in the wheelchair. V12 left the room, without hand washing, and got V11 (Restorative Aid). V11 donned gloves and V12 (CNA) did not don any PPE. V11 and V12 put a gait belt around R116 and transferred R116 to bed to use the bedpan and changed R116's soiled clothes and incontinence brief without wearing PPE. R116's shorts were visibly wet with urine. R116's Physician Orders shows R116 is on contact isolation for ESBL (a multi-drug resistant organism) in the urine. On 11/19/24 at 9:53 AM, V2 (Director of Nursing) said for residents on contact isolation, staff should don PPE before entering the room and should be wearing gown and glove when providing care. 2. R36's physician order dated 11/4/24 showed, Maintain enhanced barrier precautions (EBP) to prevent infections related to wound . R36's current care plan showed R36 required EBP due to her sacral pressure injury. The care plan showed, Ensure all staff and visitors are aware of precautions . Utilize appropriate PPE (personal protective equipment) . On 11/18/24 at 10:55 AM, V4 (CNA) and V5 (CNA) wheeled R36 into her room. An enhanced barrier precautions isolation sign on the door to R36's room. V4 and V5 transferred R36 into bed and provided incontinence care to R36, which included cleansing over and around R36's sacral pressure injury. Neither V4 nor V5 donned a protective gown prior to providing cares. On 11/19/24 at 9:10 AM, V4 (CNA) and V5 (CNA) again wheeled R36 into her room. An enhanced barrier precautions isolation sign on the door to R36's room. V4 and V5 transferred R36 into bed and provided incontinence care to R36; which included cleansing over and around R36's sacral pressure injury. Neither V4 nor V5 donned a protective gown prior to providing cares. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated if staff are providing incontinence care to a resident with a sacral wound, they are to don a protective gown and gloves prior to providing cares as per the enhanced barrier precautions guidelines. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 13 of 14 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 11/20/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm The facility's Enhanced Barrier Precautions policy dated 4/16/24 showed, Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multidrug Resistant Organisms (MDRO) . EBP may be applied to residents with any of the following: wounds or indwelling medical devices . Examples of high contact resident care activities: dressing, bathing, transferring, hygiene, changing linens, changing briefs . Residents Affected - Some 3. On 11/18/24 at 10:42 AM, V4 (CNA) and V5 (CNA) transferred R39 into bed to provide cares. V5 pulled down the front of R39's incontinence brief. V5 began wiping R39's groin and perineal area as dried stool was noted to the area. Without changing her contaminated gloves, V5 helped reposition R39 on her side as V4 wiped R39's buttocks. Without changing her contaminated gloves, V4 placed a clean incontinence brief under R39. 4. On 11/18/24 at 9:10 AM, V4 (CNA) and V5 (CNA) transferred R57 into bed to provide cares. V4 pulled down the front of R57's incontinence brief. R57 was incontinent of urine and stool. V4 provided incontinence care R57. Upon completion of these cares, V4 did not change her gloves. While wearing the contaminated gloves, V4 helped place R57 in a clean brief; touching R57, R57's bedding, and R57's bed with the soiled gloves. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated staff are to change gloves when they are dirty and before touching anything clean to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145990 If continuation sheet Page 14 of 14