Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Symphony Maple Crest during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control practices for handling soiled linens and washcloths. In one room, a friend reported stool on a resident’s bedding, and the soiled bedding was later observed placed directly on the floor, where it remained for an extended period and was stepped on by a CNA who had removed it without having a bag available. The roommate reported that staff typically put dirty linens on the floor before bagging them. In another room, soiled washcloths were observed on the floor next to a trash can with no staff present. These practices did not comply with the facility’s policy requiring soiled linens and briefs to be treated as potentially infectious and placed in plastic bags or appropriate containers for transport.
A resident with multiple comorbidities and a history of pressure ulcers developed two new pressure injuries on the buttocks that were not identified by staff until they became unstageable. Despite orders for regular skin checks, the wounds progressed to advanced stages, with one requiring debridement and being classified as a stage 4 pressure injury. Staff interviews indicated that the resident's preference to remain seated and refusal of showers limited opportunities for thorough skin assessments.
A newly admitted resident with multiple diagnoses did not receive their prescribed medications for a scheduled dose. The facility's staff failed to administer medications as ordered, despite having a convenience box and a policy for safe medication administration. The resident's daughter brought medications, but the facility had already ordered them from their pharmacy.
The facility failed to provide adequate staffing, resulting in delayed care and unmet needs for residents. Residents experienced long waits for incontinence care, and staff were distracted by personal cell phones. Several residents were found with saturated briefs, and one developed a pressure injury due to inadequate wound care. The facility also had a high medication error rate and failed to provide snacks consistently, as indicated by a one-star staffing rating.
The facility failed to label opened insulin bottles and pens with expiration dates for four residents, as required by their medication storage policy. An LPN confirmed that insulin should be dated when opened, typically expiring 28 days later. The facility's policy mandates labeling opened medications with a date opened sticker and a new expiration date, which was not followed in this case.
The facility failed to follow infection control protocols, with staff not wearing PPE in contact isolation and enhanced barrier precaution situations, and not changing gloves during incontinence care, risking cross-contamination. A CNA entered a contact isolation room without PPE, and two CNAs did not wear gowns while caring for a resident with a pressure injury. Additionally, CNAs did not change gloves after providing incontinence care, contrary to facility policies.
A resident's privacy and dignity were compromised when a CNA provided peri-care with the room door open, exposing the resident to the hallway. The resident was later seen in a shower chair with their pants down, being pushed down the hallway, leaving fecal matter on the floor. This violated the facility's policy requiring privacy during incontinence care.
Three residents requiring extensive assistance with incontinence care were left in saturated briefs for extended periods, leading to wet clothing and skin irritation. Despite the facility's policy to check and change residents every two hours, this was not followed, resulting in inadequate care.
The facility failed to conduct weekly wound assessments and ensure proper pressure ulcer care for two residents. One resident developed a new unstageable pressure injury that was not consistently dressed, and another resident with a Stage 3 heel ulcer was not provided with the recommended heel boots to off-load pressure. Staffing issues contributed to these deficiencies.
A resident with dementia and dysphagia experienced significant weight loss, dropping from 126.4 lbs to 117.2 lbs in one month. The facility failed to conduct weekly weight monitoring as recommended by the RD and did not provide the prescribed supercereal at breakfast. The facility's policy required re-weighing and notifying the physician and RD for significant weight changes, but these steps were not followed.
The facility failed to properly administer and manage oxygen therapy for two residents. A resident was switched to a portable oxygen tank by non-nursing staff without a physician's order, and another resident's oxygen tubing was not changed weekly as required. These actions were against the facility's protocols and physician orders.
The facility experienced a 31.25% medication error rate due to late administration of medications to three residents. An LPN administered medications late to a resident due to being behind schedule, while another LPN was delayed by attending to a deceased resident. The facility's medication pass schedule was not followed, leading to errors.
Two residents in an LTC facility suffered injuries due to inadequate supervision and failure to follow safety protocols. One resident, with a history of falls, attempted to self-transfer without a gait belt, resulting in a femur fracture. Another resident, with Parkinson's and a fractured arm, fell from a wheelchair lacking foot pedals during transport, requiring 21 sutures. Both incidents highlight the facility's failure to adhere to safety policies and provide adequate staff support.
A resident with cognitive impairments and decreased safety awareness sustained severe burns after spilling hot coffee on her thighs. The facility failed to monitor and log the temperatures of hot beverages before serving them, with the hot water machine set at a high temperature. Staff interviews revealed a lack of awareness and training regarding safe hot beverage handling, contributing to the deficiency.
A resident who requires assistance with ADLs did not receive scheduled showers, leading to discomfort and an itchy scalp. The resident, who has no cognitive impairment, reported missing showers on her designated days. The DON confirmed the oversight and acknowledged the importance of adhering to the shower schedule for hygiene purposes.
A resident with bladder incontinence and a history of UTIs was not provided thorough incontinence care, as a CNA only cleaned the frontal area and neglected the buttocks and thighs. This was against the facility's policy and care plan, which aimed to prevent skin breakdown and infection. An LPN confirmed the need for comprehensive cleaning to avoid skin irritations.
A resident with dementia and other health issues experienced verbal abuse from a CNA, who yelled at him and pushed him into his room, violating the facility's abuse prevention policy. The incident was witnessed by staff, leading to the CNA's termination.
The facility failed to ensure newly-hired nursing staff received dementia care training before caring for residents. Several CNAs and an LPN worked multiple shifts without the required training, as confirmed by interviews and record reviews. The HR and DON acknowledged the lapse, citing immediate staffing needs and recent changes in leadership.
The facility failed to supervise a dementia resident, leading to the resident wandering into other residents' rooms. Despite a care plan indicating the need for close monitoring, staff did not adequately supervise the resident, resulting in multiple incidents and distress to other residents. Staff also reported not receiving dementia training, contributing to the inadequate supervision.
Improper Handling of Soiled Linens and Washcloths
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to the handling of soiled linens and washcloths for multiple residents. On one occasion, a friend of a resident reported stool on the resident’s bedding to the Laundry and Housekeeping Manager, who stated she would inform staff that the bedding needed to be changed. Shortly thereafter, surveyors observed the soiled bedding from that resident’s bed placed directly on the floor with nothing underneath it. The resident’s roommate reported that staff usually put dirty linen on the floor and then bag it when they are done. A CNA acknowledged placing the bedding on the floor because she realized there was no bag available after removing the soiled linens and left to get one. Later the same day, the soiled bedding remained on the floor, and the same CNA stepped on it while walking past to retrieve an item. Another staff member, identified as a CNA/Ward Clerk, stated that soiled linens should be either in a bag or in the linen room, and the CNA reiterated that she had removed the bedding before realizing she did not have a bag. In a separate observation that afternoon, another surveyor found soiled washcloths on the floor next to a trash can in another resident’s room, with no staff present. The facility’s written Laundry and Linen Handling & Storage policy specified that linen, clean or soiled, should not touch clothing or uniforms, that all soiled linen should be handled as potentially infectious, and that soiled linens and briefs should be placed in plastic bags or appropriate containers for transport, which was not followed in these instances.
Failure to Timely Identify and Assess Pressure Injuries
Penalty
Summary
The facility failed to identify two areas of pressure injury on a resident until the wounds became unstageable. The resident, who had diagnoses including Type 2 Diabetes Mellitus, peripheral vascular disease, and existing stage three and stage four pressure ulcers, was cognitively intact and required moderate assistance with personal hygiene. Despite physician orders for skin checks to be completed twice weekly, new pressure areas on the resident's left and right buttocks were not detected until they had progressed to unstageable wounds, as documented in wound assessment reports. One of these wounds required debridement and was subsequently classified as a stage four pressure injury, while the other was identified as a stage three pressure injury. Interviews with facility staff revealed that the resident preferred to remain seated in a wheelchair throughout the day, often using a bedpan in the chair and refusing showers, which limited opportunities for staff to observe the skin on the buttocks. The Assistant Director of Nursing acknowledged that the new pressure ulcers should have been identified before reaching advanced stages. The DON confirmed that staff responsible for the resident's care were also responsible for conducting skin checks. The wound care physician noted that the resident's constant sitting and reluctance to move contributed to the development of the pressure ulcers, and that the wounds were already advanced when first assessed.
Failure to Administer Medications as Ordered for Newly Admitted Resident
Penalty
Summary
The facility failed to administer medications as ordered to a newly admitted resident, identified as R1, who was part of a sample of six residents reviewed for medication administration. R1 was admitted with multiple diagnoses, including Diabetes Mellitus, Malnutrition, Hodgkin's Lymphoma, Chronic Gout, Benign Prostatic Hyperplasia, and Weakness. The Medication Administration Record for February indicated that R1 had several prescribed medications, including Allopurinol, Atorvastatin, Flomax, Lantus, Eliquis, Famotidine, Magnesium Oxide, Metformin, and Senna Plus. However, none of these medications were administered for the 7:00 PM dose on February 19, 2025. Interviews with facility staff revealed that the resident's daughter brought in medications on February 20, 2025, which were handed over to a registered nurse, V3. The nurse mentioned that the facility had already ordered the medications from their pharmacy. The Director of Nursing, V2, confirmed the existence of a convenience box for medication access and stated that staff should contact the doctor for substitute orders if medications are unavailable. The facility's policy on medication administration emphasizes the provision of safe and accurate medication administration to residents, which was not adhered to in this instance.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in significant delays in care and unmet needs. Residents reported waiting for extended periods for assistance with incontinence care, with one resident waiting up to 2.5 hours. This delay in care was particularly problematic during the afternoon and weekend shifts. Additionally, residents expressed concerns about staff being distracted by personal cell phones, which contributed to the lack of timely assistance. The facility's policy prohibits cell phone use on the floor, yet this rule was not enforced, leading to further neglect of resident needs. The facility also failed to provide adequate care for residents dependent on staff for activities of daily living (ADLs), such as toileting. Several residents were found with saturated incontinence briefs, indicating infrequent changes and inadequate care. One resident developed a pressure injury that was not properly assessed or treated due to the absence of a wound nurse and the departure of the Director of Nursing. The facility's failure to maintain proper wound care protocols resulted in the resident's pressure injury being left uncovered and untreated. Furthermore, the facility exhibited a high medication administration error rate of 31.25 percent, with medications not being provided on time due to staff attending to other residents. The facility's staffing data report indicated a one-star staffing rating, highlighting the insufficient staffing levels. Residents also reported not receiving snacks as per the facility's policy, with the responsibility of distribution falling on the nursing staff, who failed to provide them consistently.
Failure to Label Insulin with Expiration Dates
Penalty
Summary
The facility failed to ensure that opened, multi-dose insulin bottles and insulin pens were labeled with expiration dates for four residents. The residents involved were receiving various types of insulin, including Lantus, Aspart, and Lispro, as per their physician orders. During an inspection of the medication cart on the 100 wing, it was observed that insulin pens and bottles for these residents were opened but not labeled with expiration dates. This oversight was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that insulin should be dated when opened to track its expiration, typically 28 days after opening. The facility's policy on medication storage, dated November 2021, mandates that medications and biologicals be stored safely and properly, following manufacturer or supplier recommendations. The policy specifically requires that once certain medications, such as insulins, are opened, they must be labeled with a date opened sticker and a new expiration date. The failure to adhere to this policy resulted in the deficiency noted during the survey, as the insulin medications for the residents were not labeled with the necessary expiration information.
Infection Control Deficiencies in PPE Use and Glove Changes
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not wearing appropriate Personal Protective Equipment (PPE) in contact isolation and enhanced barrier precaution situations. In one instance, a Certified Nursing Assistant (CNA) entered a contact isolation room without donning PPE and assisted a resident with incontinence care, despite the resident being on contact isolation for a multi-drug resistant organism (ESBL) in the urine. Additionally, two CNAs failed to wear protective gowns while providing incontinence care to a resident with a sacral pressure injury, despite the resident's care plan requiring enhanced barrier precautions. Further deficiencies were observed in the failure to change gloves during incontinence care, leading to potential cross-contamination. In one case, a CNA did not change gloves after cleaning a resident's groin and perineal area, and then proceeded to reposition the resident and handle clean items. Similarly, another CNA did not change gloves after providing incontinence care to a resident, subsequently touching the resident, their bedding, and bed with contaminated gloves. These actions were contrary to the facility's infection control policies, which require glove changes when they become dirty and before touching clean items.
Violation of Resident Privacy and Dignity During ADL Care
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and privacy was maintained during the provision of Activities of Daily Living (ADL) care. On November 19, 2024, a resident was observed in a compromising situation where their buttocks and posterior thighs were visible from the hallway while a Certified Nursing Assistant (CNA) provided peri-care with the room door open. Later, the same resident was seen sitting in a shower chair with their pants around their knees, being pushed down the hallway by the CNA, with fecal matter dropping onto the floor every few feet. This incident was contrary to the facility's Incontinence Care policy, which mandates providing privacy for residents during such care. On November 20, 2024, another CNA stated that the standard procedure before providing peri-care includes washing hands, donning appropriate Personal Protective Equipment (PPE), and closing the resident's room door to ensure privacy. The failure to adhere to these procedures resulted in a breach of the resident's rights to dignity and privacy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents who required staff support for incontinence care and toileting. Resident 21, who needed extensive assistance for toileting, transferring, and repositioning, was found in a wet incontinence brief and wheelchair pad, indicating a lack of timely care. Despite expressing the need to urinate, Resident 21 was not attended to until much later, resulting in a saturated brief and wet clothing. Similarly, Resident 1, who was completely dependent on staff for repositioning and toileting, was found with a saturated incontinence brief and red buttocks, suggesting prolonged exposure to urine. The brief had not been changed since early morning, despite a noticeable urine odor in the room. Resident 40, also requiring extensive assistance, was left in a saturated brief for several hours, leading to bright red skin in the groin and buttocks area. The facility's administrator confirmed that residents should be checked and changed every two hours, which was not adhered to in these cases.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to complete weekly wound assessments and ensure proper pressure ulcer care for two residents. One resident, who was at risk for impaired skin integrity due to decreased mobility, incontinence, and dementia, developed a new unstageable pressure injury on the sacral area. Despite physician orders for specific wound care, the resident's wound was not consistently dressed, and weekly assessments were not conducted. The facility's administrator acknowledged the lapse in care, attributing it to staffing issues, including the departure of the wound nurse and the Director of Nursing. Another resident with a Stage 3 pressure wound on the right heel was observed without the recommended heel boots, which were intended to off-load pressure and aid in healing. The wound nurse confirmed that the resident's heels should be offloaded with heel boots or pillows to prevent contact with the mattress. The facility's Skin Management Program policy emphasized the need for ongoing monitoring and evaluation to ensure optimal outcomes, which was not adhered to in these cases.
Failure to Implement Weight Loss Interventions for a Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of significant weight loss received the necessary interventions as ordered by the dietitian. The resident, who was at risk for malnutrition due to dementia and dysphagia, experienced a weight drop from 126.4 pounds to 117.2 pounds within a month, indicating a 7.28% weight loss. Despite the dietitian's recommendation for weekly weight monitoring over four weeks, the facility did not document any weekly weights for the resident during the specified period. Additionally, the resident was not provided with the prescribed supercereal at breakfast, which was intended to address the weight loss by adding calories and protein to the diet. The dietary manager confirmed that the resident did not receive supercereal with breakfast, as indicated on the meal ticket. The dietitian acknowledged that the recommended weekly weigh-ins were not conducted, and the resident did not receive the prescribed dietary intervention. The facility's policy on communication of weight concerns required re-weighing and notifying the physician and dietitian in the event of significant weight changes, followed by appropriate interventions and care plan updates. However, these procedures were not followed, contributing to the deficiency in care for the resident.
Deficiencies in Oxygen Administration and Management
Penalty
Summary
The facility failed to ensure proper administration and management of oxygen therapy for two residents. In the first instance, a certified nursing assistant and a restorative aid were observed assisting a resident, R116, with a nasal cannula connected to an oxygen concentrator set at 2 liters. They attempted to switch the resident to a portable oxygen tank without the involvement of a nurse, which is against the facility's protocol. The Director of Nursing confirmed that only nurses should administer oxygen and set the dial according to the physician's order. Furthermore, it was revealed that there was no physician order for R116's oxygen therapy at the time of the observation, although an order was later documented specifying 2 liters of oxygen via nasal cannula for COPD management. In the second instance, another resident, R31, was found using oxygen tubing that had not been changed since 11/4/24, despite the facility's policy requiring weekly changes. The Assistant Director of Nursing confirmed that the tubing should be changed weekly and as needed. R31's physician orders also indicated that the oxygen tubing should be changed weekly. The facility's procedure for oxygen administration, dated August 2024, mandates that the oxygen delivery device and tubing be changed weekly or as needed, with the tubing dated to track changes. These oversights in oxygen management and adherence to physician orders and facility protocols contributed to the deficiencies identified during the survey.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 31.25%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed during a medication pass involving three residents. For Resident 60, medications including Carvedilol, Calcium/Vitamin D, PreserVision, Tramadol, and Tylenol were administered late at 9:46 AM instead of the prescribed 8 AM. The LPN responsible for the medication pass admitted to running late and still learning the residents, which contributed to the delay. The facility's policy considers medication administration late if it occurs one hour or more after the prescribed time. Additionally, two other residents, R117 and R11, received their medications late, with their EMAR tabs indicating a delay. The LPN administering these medications explained that the delay was due to attending to a resident who had passed away earlier that morning. The medications for these residents included aspirin, bupropion, losartan, multivitamins, and other prescribed drugs. The facility's medication pass schedule was provided, showing specific times for medication administration, which were not adhered to in these instances.
Failure to Ensure Safe Transfers and Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, resulting in significant injuries. The first resident, an elderly male with a history of frequent falls and cognitive impairment, attempted to self-transfer from the bed to a wheelchair without assistance. During this attempt, his legs crossed, causing him to fall and sustain a right femur fracture. Staff members present did not use a gait belt, which was required by the facility's policy for safe transfers. The resident was known to be impulsive and required frequent cueing, yet the staff did not adequately supervise or assist him during the transfer, leading to his injury. The second incident involved a female resident with Parkinson's disease and a fractured left arm, who fell from her wheelchair while being transported to a doctor's appointment. The resident was being pushed by her husband and a facility activity aid, who was not a CNA, on a windy day. The wheelchair lacked foot pedals, and the resident was unable to stabilize herself due to her arm brace. The sidewalk's slope contributed to the resident leaning forward and falling out of the wheelchair, resulting in a laceration that required 21 sutures. The facility's failure to ensure the wheelchair was equipped with foot pedals and to provide adequate staff assistance during transport contributed to the accident. Both incidents highlight the facility's failure to adhere to its own safety policies and adequately supervise residents at high risk for falls. The lack of proper equipment and insufficient staff support during critical moments of resident care led to preventable injuries. These deficiencies underscore the need for strict adherence to safety protocols and comprehensive staff training to prevent similar occurrences in the future.
Failure to Monitor Hot Beverage Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to monitor the temperatures of hot beverages before serving them to residents, leading to a resident sustaining severe burns. The incident involved a resident with a history of spinal stenosis, dementia, Parkinson's disease with dyskinesia, and neuropathy of the lower limbs, who had severe cognitive impairment and decreased safety awareness. On the day of the incident, the resident spilled hot coffee on her thighs, resulting in second and third-degree burns. Observations revealed that the facility's dietary staff did not check or log the temperatures of hot beverages before serving them to residents. The hot water machine was set at a high temperature, and there was no established procedure for ensuring the safety of hot beverages. The Dietary Manager admitted to not checking the temperature of the coffee since starting at the facility and was unaware of the appropriate serving temperature for hot liquids. Interviews with staff indicated a lack of awareness and training regarding the safe handling of hot beverages. The Dietary Manager and Dietary Aid both confirmed that there was no temperature log for hot beverages, and the coffee temperature was not checked before serving. The Administrator was informed of the incident but did not implement immediate measures to monitor hot beverage temperatures, contributing to the deficiency.
Removal Plan
- 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. 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.
- 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.
- 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.
- Screening for safe handling of hot beverages audit tool to be completed by DON/designee and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director.
- Hot beverage temperature audit tool to be completed by Dietary Manager/Administrator and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to provide showers to a resident who requires assistance with activities of daily living (ADL). The resident, identified as R3, has no cognitive impairment and relies on staff for bathing and personal hygiene. According to R3's care plan, she is scheduled to receive showers on Mondays and Thursdays. However, R3 reported that she had not received a shower or had her hair washed since July 1st, despite her scheduled shower days. On July 10th, R3 expressed discomfort due to an itchy scalp and mentioned that she had only been able to wash up in her sink. The Director of Nursing confirmed the resident's shower schedule and acknowledged that all residents should receive showers as per their schedule for hygiene purposes.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide adequate incontinence care to a resident, identified as R2, who is incontinent of bladder function and has a history of urinary tract infections. On the morning of July 10, 2024, R2 was observed sitting in a wheelchair with a strong urine odor. A Certified Nursing Assistant (CNA) removed a urine-soiled incontinent brief and only wiped R2's frontal area, neglecting to cleanse the buttocks or thigh area before applying a new brief. This incomplete care was contrary to the facility's policy and R2's care plan, which emphasized thorough cleaning to prevent skin breakdown and infection. A Licensed Practical Nurse (LPN) later confirmed that thorough incontinence care should include the back area, buttocks, and thighs to prevent skin irritations and redness, which R2 was already experiencing.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a male resident. The resident, who is alert and oriented with occasional forgetfulness and confusion, has a medical history that includes diabetes, atrial fibrillation, dementia with psychotic disturbance, depression, chronic kidney disease, and congestive heart failure. On the day of the incident, a Registered Nurse (RN) reported that the CNA was observed yelling at the resident, telling him to shut up and go to his room, and subsequently slamming the door. The RN intervened, reminding the CNA that the resident was a fall risk and should not be left alone with the door shut. Interviews with staff and the resident confirmed the occurrence of verbal abuse. The resident did not recall the incident when interviewed later, but staff members provided consistent accounts of the CNA's inappropriate behavior. The CNA was reported to have pushed the resident in his wheelchair into his room and slammed the door after telling him to be quiet. The facility's abuse prevention policy, which prohibits all forms of abuse and has a no-tolerance philosophy, was violated in this instance. The CNA involved was terminated following a substantiated investigation into the abuse allegation.
Failure to Provide Dementia Training to Newly-Hired Staff
Penalty
Summary
The facility failed to ensure that newly-hired nursing staff received dementia care training and education prior to caring for residents. This deficiency was identified through interviews and record reviews, which revealed that several CNAs and an LPN had not received the required dementia training upon hire. Specifically, V3 CNA, V4 CNA, V7 CNA, and V8 LPN were all found to have worked multiple shifts without having completed the necessary dementia training. The facility's General Orientation Checklist indicated that dementia care education should be provided during orientation, but this was not adhered to in these cases. V9 HR admitted that the newly hired staff had not gone through orientation due to the immediate need to have them on the floor. V2 DON, who had only been in her role for three weeks, acknowledged that staff should receive dementia training upon hire and annually thereafter. However, she could not account for the training status of staff hired before her tenure. This lapse in training has the potential to affect all 73 residents in the facility, as proper dementia care and monitoring are critical for resident well-being.
Failure to Supervise Dementia Resident
Penalty
Summary
The facility failed to supervise a resident diagnosed with dementia, leading to the resident wandering into other residents' rooms. The care plan for the resident, who was cognitively impaired due to dementia, indicated behaviors such as wandering, rummaging through others' belongings, confusion, poor judgment, impulsivity, and delusions. Despite these documented behaviors, the staff did not adequately monitor the resident, resulting in multiple incidents where the resident attempted to enter another resident's room, causing distress to the other resident. On one occasion, a cognitively intact resident threw water on the dementia resident to prevent her from entering his room after she had repeatedly tried to do so. The cognitively intact resident expressed frustration that staff were not intervening despite being aware of the situation. Interviews with staff members revealed that the dementia resident frequently wandered into other residents' rooms and that staff found it challenging to keep track of her movements. Some staff members also reported not receiving dementia training, which may have contributed to the inadequate supervision. The facility's policies on dementia care and wandering indicated that residents with such behaviors should be closely monitored and have individualized care plans. However, the staff did not consistently implement these policies, as evidenced by the lack of frequent checks and the failure to redirect the resident effectively. The administrator acknowledged that staff should have been checking on the resident's whereabouts every 15-30 minutes to prevent such incidents, but this was not done, leading to the deficiency in care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Belvidere
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belvidere Health And Rehab | 3.3 mi | — | 2 | 0 |
| Symphony Northwoods | 3.8 mi | — | 16 | 0 |
| Alden Debes Rehab & Hcc | 7.7 mi | — | 13 | 0 |
| Alden Park Strathmoor | 7.9 mi | — | 4 | 0 |
| Forest City Rehab & Nrsg Ctr | 8.1 mi | — | 18 | 0 |
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