Arc At Normal

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

09/19/25, Resident R3's record review of undated care plan documents an admission date of 10/06/2023 with diagnosis Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbance, Presence of Other Specified Functional Implants, REM Sleep Behavior Disorder, Visual Hallucinations, Dementia, Unspecified Severity, with Agitation, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, History of Falling, Acute Kidney Failure, and Major Depressive Disorder. The same care plan documents: Resident R3 is at risk for fall related to weakness and needs assist with mobility. History of falls. Date Initiated: 10/09/2023 Revision on: 01/10/2025. Resident R3 will reduce his risk of injuries from falls by the next review date. Date Initiated: 10/07/2023 Revision on: 07/31/2025 Target Date: 11/27/2025. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 10/09/2023. Encourage resident to be in common area during mealtimes Date Initiated: 05/15/2024. Encourage resident to lay down when visibly tired Date Initiated: 03/24/2025. Ensure all supplies are within reach when providing cares Date Initiated: 02/14/2025. Environmental rounding to ensure resident is positioned in the middle of the bed. Date Initiated: 03/11/2025. Resident R3 has stated verbally Resident R3 prefers to sit/lay on the floor directly, and at times will move himself to the floor. Date Initiated: 05/21/2024 Revision on: 05/21/2024. Offer alternate seating when patient is visibly tired or restless Date Initiated: 09/04/2025. Offer resident fluids and snack after early a.m. get up Date Initiated: 06/24/2024. Offer to adjust positioning of chair when resident visibly tired as he allows Date Initiated: 01/10/2025. Place floor mat on the floor next to bed. Date Initiated: 10/13/2023 Revision on: 10/24/2023 Place snacks in easily accessible area Date Initiated: 03/31/2025On 09/19/25, Resident R3's record

review of Minimum Data Set completed on 9/2/25 documents a Brief Interview for Mental Status (BIMS) score of 13. A score of 13 indicates Resident R3 is cognitively intact.On 09/19/25, Resident R3's record review of progress note dated 9/6/2025 at 06:14am documents V9 was on hall three middle way and turned to push the medication cart and observed Resident R3 crawling in the hallway to the common area fully clothed with one slipper sock on.On 09/19/25, Resident R3's record review documents a progress note entered by V3 Director of Nursing, dated 9/8/2025 at 10:09am stating that the Interdisciplinary Team (IDT) met to discuss the fall. Root cause: resident purposefully placed self on floor to crawl. Intervention: resident care planned to crawl on floor. when desired.On 09/21/25 at 11:30am, V1 Administrator, confirmed Resident R3's care plan had not been revised/updated with new intervention.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Arc at Normal

509 North Adelaide Normal, IL 61761

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

seatbelt broke but was it broke after admission to the facility. Resident R1 stated nursing staff are aware the seat belt is broken. On 9/19/25 at 12:59pm, V9 stated Resident R1 called V9 from Resident R1's cell phone indicating Resident R1 needed help with the straps of the lift sling as they were caught under the wheel of the wheelchair. V9 stated V9 delivered the coffee V9 had and then proceeded outside to Resident R1's location and Resident R1 was sitting on the ground.

V9 stated Resident R1 stated Resident R1 fell from the wheelchair due to the straps of the sling being under the wheels of the power chair. V9 stated Resident R1 was assessed and gotten off the ground and returned to the wheelchair and the straps were then tucked under Resident R1 to prevent further incidents. V9 stated Resident R1 should be care planned to have

the straps of the lift sling tucked under Resident R1 to prevent further incidents.On 09/21/2025 at 08:54am, V4 Maintenance Director, stated V4 was unaware of the broken seatbelt on Resident R1's wheelchair. V4 stated staff use the TELS computer program (maintenance request platform) to request service/repair orders for equipment needing repair.On 09/21/2025 at 09:43am, Resident R1 stated that Resident R1 wears the seatbelt at all times when Resident R1 is in the wheelchair and had the seatbelt been working it would have been worn and Resident R1 would not have fallen from the wheelchair.On 09/21/2025 at 11:03am, V1 Administrator, confirmed Resident R1 fell from the wheelchair on 09/12/25 and the care plan did not have proper interventions to prevent a fall from the wheelchair. On 09/21/2025 at 11:33am, V11 (R1s Family), confirmed the seatbelt on Resident R1's wheelchair was functioning upon admission and broke during Resident R1's stay. V11 confirmed Resident R1 wears the seatbelt to prevent falls from the wheelchair.

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