ARC at Normal: Wheelchair Fall After Broken Seatbelt - IL
The resident, identified in inspection records only as R1, told inspectors that the seatbelt had been working when they were admitted to the facility and broke sometime during their stay. R1 wore the seatbelt every time they were in the wheelchair. It was the only thing preventing a fall.
Nobody fixed it. Nobody filed a maintenance request. The Maintenance Director told inspectors on September 21 that he was completely unaware the seatbelt was broken. Staff use a computer program called TELS to submit repair requests. No request had been submitted for R1's wheelchair.
R1 fell on September 12.
The circumstances of the fall came into focus through what happened seven days later. On September 19, at 12:59 in the afternoon, a staff member identified as V9 received a phone call from R1. R1 was calling from a cell phone. R1 needed help because the straps of the lift sling attached to the wheelchair had gotten caught under the wheels of the power chair.
V9 finished delivering a coffee first. Then V9 went outside to where R1 was. R1 was sitting on the ground.
R1 told V9 that the sling straps catching under the wheels had caused the fall from the wheelchair. V9 assessed R1, helped R1 up, and returned R1 to the wheelchair. Then V9 tucked the sling straps underneath R1 to keep them from getting caught again.
V9 told inspectors that R1 should be care planned to have the straps tucked in as a standard precaution going forward.
But there was no care plan. The administrator confirmed it on September 21. R1 had fallen from the wheelchair on September 12, and as of the inspection date nine days later, the care plan still contained no interventions to prevent another fall from the wheelchair.
R1 had told nursing staff the seatbelt was broken. That was known. What didn't happen was anything after that, no repair order, no workaround documented in the care plan, no communication to the Maintenance Director whose job it was to fix equipment.
R1 told inspectors plainly: if the seatbelt had been working, R1 would have been wearing it, and R1 would not have fallen.
R1's family member confirmed the same sequence. The seatbelt was functional when R1 arrived at the facility. It broke during the stay. R1 always wore it to prevent falls from the wheelchair. The family knew. Nursing staff knew. Maintenance did not.
The inspection was filed under F0689, which covers accidents and the environment, with a harm level of minimal harm or potential for actual harm affecting a few residents.
What the record captures is a resident who understood exactly what they needed to stay safe, communicated that need, and then fell anyway, because the system between a broken piece of equipment and the person responsible for fixing it had no working parts either. A staff member who got a distress call finished delivering a coffee before going to check. The care plan that should have reflected a fall risk after September 12 still had nothing in it nine days later.
R1 was sitting on the ground outside, calling for help on a cell phone, while the sling straps from a lift they apparently used regularly were tangled in the wheels of their power chair.
The seatbelt, the family said, had worked fine when R1 moved in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Normal from 2025-09-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 14, 2026 · Our methodology
ARC AT NORMAL in NORMAL, IL was cited for violations during a health inspection on September 21, 2025.
R1 wore the seatbelt every time they were in the wheelchair.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.