Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 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.
Failure to provide and document bathing for a resident. A family member reported the resident appeared unkempt, with dirty, matted hair and dirty fingernails, and record review showed no shower, bath, or bed bath was provided or documented over a multi-week period. The ADM stated bathing should be offered at least twice weekly, and the facility policy required weekly showers and/or bed baths unless otherwise ordered by the MD.
Unauthorized Non-Staff Individual Provided Resident Care: A CNA brought a non-staff individual into resident care areas, where he was seen assisting with incontinence care, transfers, repositioning, and changing clothes for multiple residents. Residents reported that he was introduced as the CNA’s friend or boyfriend and that he was present during personal care, while staff later confirmed he was not an employee and had not been screened, trained, or authorized to provide care.
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.
Delayed Transfers and Incontinence Care: Staff did not transfer one resident out of bed in a timely manner because a sling was not available, leaving the resident in bed for prolonged periods and crying that it was depressing. Staff also failed to provide timely toileting and incontinence care for another resident who requested to use the bathroom, was observed with wet clothing and a strong odor of BM in the dining room, and was later found saturated with stool during transfer to bed.
Improper cooling of a pork roast was identified when the Dietary Manager stated the facility does not normally complete cooling logs and no cooling log was done for the roast. The roast was sliced for the noon meal, and the facility's recipe required potentially hazardous foods to be cooled from 135 degrees F to 70 degrees F within 2 hours and from 70 degrees F to 41 degrees F within 4 hours.
The facility failed to maintain an infection control tracking system and failed to follow PPE and hand hygiene requirements during resident care. A CNA entered a resident’s C. diff isolation room without gown and gloves, staff did not wear required gowns during wound care for residents on EBP, and CNAs did not consistently perform hand hygiene or glove changes during incontinence care, including care for a resident who was dependent for toileting and always incontinent.
Failure to Offer Activities: The facility failed to provide consistent resident activities, including on weekends, for multiple residents reviewed for activities. A cognitively intact resident stated there were no weekend activities and wanted more to help pass the time, while other residents reported that when the activity aide was off, no activities were done and weekends were limited to a movie and church service. The Administrator stated there was only one activity aide, she was acting as the activity director, and no activity calendar was posted in resident rooms or common areas.
A facility failed to maintain dignity for two hospice residents who were placed in a shared room with another resident who frequently yelled, swore, and called out loudly. Surveyors observed repeated disruptive behavior in the room and hallway while the hospice residents were present, and a resident’s daughter/POA said the environment was not peaceful for end-of-life care. Staff, including the hospice RN, RN charge nurse, DON, and ADON, acknowledged the roommate’s behavior was not conducive to a calm hospice setting.
An LPN performed wound care for a resident with a venous leg ulcer and pressure ulcer without proper hand hygiene or disinfecting scissors between handling soiled and clean dressings, creating cross-contamination during the dressing change. A second resident with edema and multiple chronic conditions was observed without ordered tubular compression stockings despite a MAR instruction to apply them in the morning and remove them at bedtime.
Pressure Injury Dressing Left Loose and Soiled: A resident with a stage 4 sacral pressure wound was found with the dressing barely attached, soiled with drainage, and the open wound uncovered when an RN entered to change it. The resident had multiple comorbidities including MS, COPD, malnutrition, and dependence for toileting and mobility assistance. The DON stated staff should monitor dressing integrity and notify the nurse if it becomes loose, comes off, or is soiled; however, the care plan did not reflect the resident’s current stage 4 pressure ulcer and treatments.
Two residents with indwelling urinary catheters received deficient catheter care. One resident’s catheter tubing was observed hanging without a secure device or leg strap in place, despite facility staff stating straps are used to prevent pulling and catheter displacement. For another resident on EBP for an indwelling catheter and MRSA history, a CNA emptied the drainage bag while the tubing end touched the container twice and then reattached it without cleaning the tubing end, although the DON stated it should have been wiped with alcohol after emptying.
Medication Administration Timing Errors: The facility had a 12% medication error rate, with an LPN giving a resident’s scheduled psychotropic and anxiety medications nearly 2 hours late. The LPN said she was still learning the process and did not ask for help, even though other nurses were available. The DON stated medication timing is part of the 5 rights and medications should be given within 60 minutes of the scheduled time.
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.
Failure to Provide and Document Resident Bathing
Penalty
Summary
The facility failed to ensure a resident was provided a shower or bed bath. During interview, the resident’s family member said he visited the resident over the weekend of 5/23/26 to 5/25/26 and observed that the resident’s hair was dirty and matted, the fingernails were dirty, and the resident appeared unkempt. Record review showed the resident’s shower task for the prior 30 days documented no shower, bath, or bed bath from 5/16/26 to 6/1/26. The Administrator stated staff should provide or offer baths or showers at least twice weekly and that documentation of showers or baths is entered in the tasks section of the electronic medical record, including if the resident refused. The facility’s Shower/Bathing policy dated 7/2025 states all residents will be offered a shower and/or bed bath at least weekly unless a physician order to the contrary is present in the medical record.
Unauthorized Non-Staff Individual Provided Resident Care
Penalty
Summary
The facility failed to protect residents from abuse when a non-staff individual who had not been screened, trained, or authorized by the facility was allowed to provide resident care. The individual was observed and reported to have been in resident rooms assisting a CNA with care, including boosting residents in bed, transferring residents with a mechanical lift, changing incontinence briefs, and helping residents change clothes. The deficiency involved four residents in the sample who were identified as having contact with the individual during these care activities. Resident interviews described the non-staff individual entering rooms with a CNA and being present while personal care was provided. One resident reported that the individual stood by while the CNA got her into bed with a mechanical lift, removed her clothes, put on her nightgown, and changed her incontinence brief. Another resident said the CNA introduced the individual as his friend and that the resident was bothered by the fact that he saw her roommate exposed. Other residents reported that the individual helped with incontinence care, repositioning, and boosting them in bed, and several said they had never seen him before and had not seen him since. Staff interviews confirmed that the individual was not an employee of the facility. The CNA said he brought his friend to the facility and had him enter through the back employee entrance, and the charge RN and receptionist both described seeing the individual with the CNA and believing he was there to work. The DON and Administrator stated that non-staff members should never be allowed to provide resident care and that the individual was not and is not an employee of the facility. The facility’s investigation also documented that staff observed the individual on the unit assisting the CNA and assumed he had been called in to help.
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.
Delayed Transfers and Incontinence Care
Penalty
Summary
The facility failed to ensure timely transfers out of bed for a resident with diagnoses including major depressive disorder, mild cognitive impairment, dysphagia, and congestive heart failure. The resident’s care plan showed she was dependent on staff for transfers and required a mechanical lift with 2 staff assist. On 9/23/2025, staff told an RN that the resident was waiting to get up but there was not a sling ready or available. When the resident was observed in her room later that morning, she was still in bed, dressed, and waiting to be gotten up. She stated that staff never got her up until close to noon and that on the prior two days they did not get her out of bed all day because they said they did not have a sling. She cried and said it was depressing and that she wanted to get up. A roommate said she heard aides tell the resident they did not have a sling and that the resident was left in bed quite a bit. The resident remained in bed until later that morning when CNAs entered with the mechanical sling lift. A CNA stated the facility had a lot of slings but that it depended on what was available, and another CNA said the resident was not gotten up until after 11:00 AM because staff had to wait for a sling. The DON stated that many residents are early birds and do not want to be left in bed, that the facility has a lot of slings, and that slings are taken down when soiled and when residents are laid down for the night. The ADON stated the resident was dependent on staff for transfers and her lower extremities were not strong enough for her to stand and transfer currently. The NP stated that not getting a resident out of bed repeatedly can affect the resident’s mental health. The facility also failed to provide timely incontinence care for another resident who required total assist for toileting and was always incontinent of bowel and bladder. During lunch, a CNA responded to a statement that the resident needed to use the bathroom by saying she was just a check and change and did not ask the resident if she needed to use the restroom or attend to her request. The resident was observed in the dining room smelling like bowel movement, with wet pants and a strong odor of BM present. Later, staff transferred the resident to bed, where her groin area and front of her pants were saturated, her brief was full of mushy and liquid stool, stool was present above the waistband on her abdomen, and the sling used for transfer was wet and had BM on it. The DON stated that incontinence care should be provided in a timely manner, residents should be toileted frequently, and when someone says they must go to the bathroom, they are toileted.
Improper Cooling of Pork Roast
Penalty
Summary
The facility failed to properly cool a pork roast after cooking. On 9/23/25 at 10:42 AM, the Dietary Manager sliced the pork roast for the noon meal and stated that the facility does not normally do cooling logs because it does not normally cook food ahead of time. The Dietary Manager said no cooling log was completed for the roast and explained that the roast had been taken out of the cooler to slice and then would be placed in the oven. The facility's recipe for Tender Pork Roast required potentially hazardous foods to be cooled from 135 degrees F to 70 degrees F within 2 hours and from 70 degrees F to 41 degrees F within 4 hours. The facility roster provided to the surveyor showed 66 residents in the building.
Infection Control Program, PPE, and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program with a system for tracking infections. The DON/IP stated she had only some infection tracking from March 2025 completed by the prior IP and that since starting in April she had not tracked any infections yet. She also stated she had not yet created the infection control tracking system and had not pulled antibiotic reports from the facility system. The Administrator stated the infection control program was not up to date and had not been a priority. The facility failed to use required PPE for a resident in contact isolation. R68 had diagnoses including osteoarthritis, hypertension, cerebral infarction, depression, and atherosclerotic heart disease, and had physician orders for enhanced barrier precautions related to ESBL and later for C. diff treatment with fidaxomicin. Surveyors observed a CNA enter R68’s room and provide repositioning assistance without PPE, despite a sign on the door stating contact precautions required gown and gloves before entry. The CNA stated she believed PPE was not needed if the stool was contained and she did not touch surfaces. The DON stated contact precautions were required for anyone infected with C. diff and that staff entering the room should wear gown and gloves at all times. The facility also failed to follow enhanced barrier precautions for residents with wounds and indwelling devices. R58 had diagnoses including chronic venous ulcer, stage 4 pressure ulcer, and diabetes, and his care plan required EBP for wounds. Surveyors observed his dressing with bloody drainage and later observed an LPN change the soiled left leg dressing without wearing a gown. R29 had a stage 4 sacral pressure wound and an indwelling urinary catheter; although an EBP sign was on the door, an RN performed wound care wearing gloves only and no gown. R11 had an indwelling catheter and was on EBP for the catheter and MRSA history; a CNA emptied the urinary drainage bag wearing gloves only, despite signage indicating gown and gloves were required for catheter care. The facility failed to prevent cross contamination during incontinence care for R57. R57 had severe cognitive impairment, was dependent for toileting hygiene, and was always incontinent of bowel and bladder. During observed incontinence care, two CNAs provided care while wearing gloves, but one CNA removed her gloves, left the room to retrieve supplies, returned and resumed care, handled clean items, and continued care without consistent hand hygiene and glove changes between dirty and clean tasks. The DON stated staff should wash hands and change gloves when soiled and when moving from dirty to clean to prevent cross contamination and transmission of bacteria, especially during peri care.
Failure to Offer Activities
Penalty
Summary
The facility failed to offer activities for 6 of 6 residents reviewed for activities, including R10, R15, R28, R44, R48, and R66. R66 stated there were no activities on the weekend and said she enjoyed some of the activities the facility provides, but would like weekend activities because they give residents something to do and help pass the time. R66’s MDS showed she was cognitively intact, and her activity assessment documented that she was a LTC resident who enjoyed staying in her room most of the day, but also liked watching TV, visiting with family, reading, word searches, arts and crafts, food-related activities, bingo, music programs, and the dine-in club. The assessment also stated it was very important for her to do her favorite activities and participate in group activities. During the Resident Council Meeting, R28, R44, and R48 stated there was only one activity staff member who was off every other Monday, Friday, and weekend, and when the activity aide was not at the facility, no activities were done. The residents said they were frustrated on weekends because they were given only a movie to watch and had to find something to do, and they were bored until Monday when the activity aide returned. The Administrator stated she was acting as the activity director because there was no one else, that the facility only had one activity aide, and that she was trying to hire another person for the days the aide was off. She also stated the facility had movies on weekends and either a physical church service or a video church service, and that there was no posted activity calendar in resident rooms, common areas, or the activity area; the facility used a handwritten calendar and tried to announce activities as they came up. The facility policy stated guests would be offered Life Enrichment that enhances physical, cognitive, spiritual, social, and emotional health.
Dignity Not Maintained for Hospice Residents
Penalty
Summary
The facility failed to maintain dignity for two hospice residents who were sharing a room with another resident who frequently yelled, swore, and called out loudly. One resident had diagnoses including dementia, depression, anxiety disorder, heart failure, protein-calorie malnutrition, and was receiving hospice services with a care plan focused on comfort and being kept as comfortable and pain free as possible. The other resident had diagnoses including anxiety disorder, depression, memory deficit following stroke, protein-calorie malnutrition, chronic kidney disease stage 3, and Parkinson’s disease, with severe cognitive impairment, one-sided range of motion impairment, and dependence on staff for transfers; she was also on hospice care with a care plan calling for emotional, physical, and spiritual support during the terminal phase of illness. Survey observations showed the roommate repeatedly yelling out in the shared room and hallway, including swearing, demanding help, and speaking loudly while the hospice residents were present. The roommate was heard yelling multiple times throughout the day, and staff described the behavior as frequent and not new. One hospice resident’s daughter/POA stated the resident had been placed on hospice for comfortable, peaceful end-of-life care and said it was not peaceful with the roommate yelling. She also reported the roommate told her to get out of the room and had made threatening statements toward her. Staff acknowledged the room was not an appropriate environment for hospice residents. The charge nurse stated the curtain had been left closed because one resident was dying and family was present, and later opened it after being informed of the roommate’s yelling and agitation. The hospice RN stated that a roommate yelling and swearing was not conducive to a calm environment. The DON and ADON also acknowledged that the two hospice residents should not have been placed with the yelling resident, and that the roommate’s behaviors made the room unfair and not the proper environment for hospice residents.
Cross Contamination During Wound Care and Missed Compression Stockings
Penalty
Summary
Wound care for a resident with chronic venous ulcer of the left leg, a stage 4 pressure ulcer of the buttock, and diabetes was performed in a way that did not prevent cross contamination. During the dressing change, the LPN used scissors to cut and remove part of the soiled dressing, placed the scissors on a clean tray without sanitizing them, changed gloves without sanitizing or washing hands, cleansed the wound, changed gloves again without hand hygiene, and then used the same scissors to cut clean oil emulsion and calcium alginate dressings before applying them to the open and draining left leg wounds. The DON stated scissors should be disinfected after cutting potentially soiled dressings and before cutting clean dressing materials, and that hand hygiene should occur before donning new gloves. A second resident with diagnoses including chronic kidney disease, dementia, peripheral vascular disease, hypothyroidism, hypertension, generalized edema, and heart failure did not have tubular compression stockings in place when observed in a wheelchair and later in bed. The resident’s MAR directed that the stockings be applied in the morning and removed at bedtime, and the MAR was signed on one date indicating they were applied, but the resident was observed without them later that same day. The RN stated the stockings are put on early in the morning by the night nurse and that there was no report of a problem, while the DON stated every physician order should be followed and that if an order is not followed it should be documented why it was not followed.
Pressure Injury Dressing Left Loose and Soiled
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when a resident with a stage 4 sacral pressure wound was found with the wound dressing not intact. On 9/23/25 at 1:57 PM, the RN entered the resident’s room to change the dressing and found the resident’s open sacral wound uncovered, with the dressing barely attached at the bottom, soiled with drainage, and an odor present. The resident’s wound care progress note dated 9/19/25 identified the sacral wound as full thickness and ordered calcium alginate with silver as the primary dressing, with gauze island border as the secondary dressing, and skin prep to the peri-wound area, each to be applied daily and as needed if saturated, soiled, or dislodged. The resident’s face sheet listed diagnoses including anxiety disorder, hypertension, depression, mild protein calorie malnutrition, postherpetic polyneuropathy, COPD, neuromuscular dysfunction, edema, and multiple sclerosis. The MDS showed the resident was dependent for toileting and needed substantial to maximal assistance for bed mobility, transfers, and dressing. The DON stated staff should monitor the wound dressing to ensure it is intact, and the CNA should notify the nurse if the dressing becomes loose, comes off, or is soiled so it can be reapplied or changed. The care plan identified the resident as at risk for impaired skin integrity, but it did not show the resident currently had a stage 4 pressure ulcer and treatments.
Catheter tubing not secured and drainage spigot not cleaned after emptying
Penalty
Summary
The facility failed to ensure appropriate catheter care for two residents with indwelling urinary catheters. For one resident with diagnoses including anxiety disorder, hypertension, depression, mild protein calorie malnutrition, COPD, neuromuscular dysfunction, edema, and multiple sclerosis, the catheter tubing was observed hanging and pulling to the side with a lot of sediment in the tube and amber urine in the drainage bag, and no secure device was in place. The RN stated secure devices are used on catheter tubing to prevent the catheter from getting pulled out, and the DON stated the facility uses leg straps for anyone with a foley and that the straps should be in place to stop pulling and tugging, help prevent breakdown, and prevent the catheter from coming out. The resident’s care plan addressed monitoring placement of tubing but did not show use of a device to anchor the tubing, and the facility’s catheter policy did not include information about securing the tubing. For another resident with diagnoses including neuromuscular dysfunction of the bladder, paraplegia, autonomic neuropathy, and anxiety disorder, the CNA emptied the urinary drainage bag while the end of the catheter tubing touched the container twice. The CNA did not clean the end of the tubing before reattaching it. The DON stated that if the tubing touched the container, it should have been cleaned with alcohol swabs, and that the end of the tubing should be wiped with an alcohol pad after the drainage bag is emptied, even if it does not touch the container, to prevent infection and keep it clean. The resident was cognitively intact, was on enhanced barrier precautions related to an indwelling catheter and history of MRSA, and was dependent on staff for toileting and peri-care. The facility’s indwelling catheter policy addressed daily cleansing, keeping the drainage bag below bladder level, keeping the bag off the floor, keeping tubing free of kinks, and emptying the bag every shift and as needed, but did not address cleaning the spigot after emptying or avoiding contact between the spigot and the container.
Medication Administration Timing Errors
Penalty
Summary
Medication error rates were not kept below 5 percent. Based on observation, interview, and record review, the facility had 25 medication administration opportunities with 3 errors, resulting in a 12% medication error rate. The errors involved R47, whose electronic face sheet dated 9/24/25 listed diagnoses including psychotic disorder with delusions, dementia without behaviors, anxiety disorder, and adjustment disorder. R47’s September 2025 MAR showed orders for Hydroxyzine 50 mg at 8 AM and 4 PM, Seroquel 25 mg at 8 AM, 12 PM, and 8 PM, and Lorazepam 2 mg at 8 AM, 12 PM, and 4 PM. During observation on 9/23/25, V5, an LPN, administered R47’s Hydroxyzine 50 mg, Seroquel 50 mg, and Lorazepam 2 mg at 9:50 AM, which was 1 hour and 50 minutes past the scheduled time. At 10:25 AM, V5 stated there was no reason for the late medication administration other than being a newer nurse still learning the process. Two other nurses were observed finished with their medication passes and available to assist, but V5 stated she did not ask for help because she needed to learn a routine to keep herself on track. V5 also stated that a lot of residents still needed medications. The DON stated that medications should be given within 1 hour before or 1 hour after the scheduled time, that there were 3 nurses on day shift who could help if asked, and that timing of medications is one of the 5 rights of medication administration. The facility policy stated medications are administered as prescribed, the 5 rights apply to each medication, and medications are administered within 60 minutes of scheduled time except before, with, or after meal orders.
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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Illustrative
What surveyors actually found near you
We read the 283 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 14 | 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 | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.