Inspection·March 4, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review the facility failed to ensure that a resident was assisted to the bathroom in a safe manner. This failure resulted in R2's legs giving out, requiring her to be lowered to the floor by staff and resulting in a right closed displaced spiral distal femoral shaft fracture on 1/14/24. This applies to 1 of 4 residents (R2) reviewed for safety in a sample of 4. The findings include: R2's Incident Report dated 1/14/24 at 6:40 AM states, Aide came to this nurse with report that while walking resident to the restroom- she stated legs/knees were giving out- aide stated she lowered resident to the floor. Upon my visual- resident lying in restroom on the floor, right side. Denies any new injury/pain. Does complain of pain to right shoulder and hip, which resident has frequently. No visual new injury. Stated her legs were giving out and the aide lowered her to the floor. R2's Progress Notes dated 1/14/24 state, 9:23 AM, Resident lying in bed on left side complaining of extreme pain to right leg. Resident requesting repositioning but crying out in pain when assisted. Resident unable to sit up in bed with assistance. Some swelling noted to right femur, no redness or bruising . Orders given for stat X-rays to Right hip and pelvis and Right femur. (Portable) X-ray called. Tech is delayed due to weather conditions but will call when closer. 11:27 AM Resident requested to go to hospital due to extreme pain without relief. POA notified and consented to transfer resident to hospital via ambulance. Ambulance called. EMTs transporting resident to hospital at approximately 11:20 AM. 3:02 PM- Resident being transferred to (Larger local hospital) d/t non-displaced spiral fracture to shaft of right femur. On 3/4/24 at 9:55 AM R2 was sitting in her recliner in her room. R2 appeared clean and well groomed. R2 was alert and pleasant and somewhat sarcastic. R2 stated, I can walk with the walker, but I have to have help. I have to call them. I am just following the rules. My leg gets tired more easily now. R2 was asked how she fell on 1/14/24. R2 stated, I had just finished scrubbing in the bathroom and I came out and I went down real easy. It wasn't like a big fall or a big hurt or anything. The x-ray showed the fracture of my leg. I didn't have surgery or anything. I don't remember if I was in the hospital or not. I'm okay now. On 3/4/24 at 10:55 AM V4 (Certified Nursing Assistant/CNA) stated, (R2) had her slipper socks on and I used a gait belt. As we were walking from the bed to the bathroom, she said her legs felt weak and I told her 'a couple more steps' and then she started to go down. I went down first, and my leg (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145062 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145062 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Streator 1525 East Main Street Streator, IL 61364 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)