Inspection·December 18, 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 provide supervision and implement fall interventions for a resident at risk for falls for one resident (R1) of three reviewed for falls in a sample of three. This failure resulted in R1 sustaining multiple falls and acquiring a displaced fracture of the left lesser trochanter. Findings include: The facility's Fall Prevention Program, dated 10/2024, documents the facility is to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. R1's Fall Risk Assessment, dated 11/19/24, documents that R1 is at risk for falls. R1's Comprehensive Incident Fall Assessment, dated 11/8/24, documents that R1 was sitting on the floor next to her bed. R1 stated that she was trying to go to breakfast. R1 didn't realize it was bedtime. This form documents that safety interventions are already in place. No new fall interventions were implemented. R1's Comprehensive Incident Fall Assessment, dated 11/10/24, documents that R1 was sitting on the floor with her back against her roommate's recliner. R1 stated that she was walking out of the bathroom without her walker or wheelchair, tripped over the catheter bag. R1's skin assessment documents a skin tear 3.7cm (Centimeters) on her right shin and a 5cm by 1.1cm skin tear on her right forearm. No new immediate fall interventions were put into place. R1's Comprehensive Incident Fall Assessment, dated 11/12/24 at 10:15am, documents that R1 was yelling out for help. R1 was sitting on her buttocks on the floor upon entering the room. R1 stated that she was getting up for lunch and fell. R1's call light was off. R1's wheelchair with her catheter bag was next to R1. R1 sustained a 2cm by 2cm lump and a bruise to her left forehead. R1 also sustained a 0.5cm by 0.2cm bruise to her left elbow and a 4cm by 4cm skin tear to her left lower extremity. R1's fall intervention was to keep R1 within nurses' sight. R1's Comprehensive Incident Fall Assessment, dated 11/30/24 at 11:00am, documents that V5 (Registered Nurse/RN), and V6 (RN) and V7 (Licensed Practical Nurse/LPN), were at the southwest nurses' station when they heard a loud yell, upon exited the nurses' station, R1 was noted lying on her back on the floor in the middle of the southeast hallway. Upon assessment R1 was eliciting pain to her left (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 12/18/2024 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)