Health inspection·February 6, 2026

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were treated in a dignified manner by responding to their call lights in a reasonable amount of time. This applies to 2 of 5 residents (R1 & R5) reviewed for dignity in the sample of 5. The findings include: On 2/6/26 at 10:10 AM R1 stated, It takes a long time for the call light to be answered. I usually have to go to the bathroom. This morning, I waited 30 minutes. When you have to move your bowels, you have got to get there. Today I thought I was going to go in my chair because I waited so long for someone to come. I would be so embarrassed. That is just not me.R1's Minimum Data Set assessment dated [DATE] shows that R1 has no cognitive impairment. R1's Care Plan dated 6/7/24 states, I am extensive transfer and ambulation to bathroom with rolling walker.On 2/6/26 at 11:45 AM, R5 stated, If I gotta go, I gotta go. Sometimes I have had to go in my pants because they take so long or I take myself to the bathroom. This morning, I sat on the edge of that bed for 30 minutes waiting to go take a crap and I finally I walked into the bathroom, and my diaper was full of crap because I couldn't wait anymore. R5's son, sitting next to her told R5 that she is not supposed to walk by herself and R5 stated, I have to, if they don't come.R5's Minimum Data Set assessment dated [DATE] shows that R5 has no cognitive impairment. R5's Care Plan dated 1/17/26 states, The resident requires assist with toileting.The facility Resident Council Minutes for January 2026 state, More help, CNA's. Page 1 of 2 145062 145062 02/06/2026 Arc at Streator 1525 East Main Street Streator, IL 61364

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure staff safely transfer a resident from her recliner to her wheelchair to prevent injury. This applies to 1 of 4 residents (R1) reviewed for falls in the sample of 5.The findings include:On 2/6/26 at 10:10AM R1 stated, I got up in the AM. The CNA helped me and brought my wheelchair in. She locked one side but didn't lock the other so when I sat down the chair flipped, and I went flying and fell on my left side. I did not have a gait belt on. I had a cut on my elbow and 2 cuts on my left leg. and I hit my head on the floor. They kept checking me over and over- kept shining a light in my eyes. They never used a gait belt until now. They don't have enough staff. I was so scared. It was an awful fall. I always ask them to lock the wheelchair now and make sure it is locked before I stand up. I am going to stay in the room today and do not plan on transferring out of the chair. I leave the gait belt on. R1 pulled back her blanket to show the gait belt around her waist. R1 said I don't trust them.On 2/6/26 at 12:00PM, V4 (Certified Nursing Assistant/CNA) stated, I got the chair and locked the one side, then before I could lock the other side (R1) turned and sat on the armrest/wheel and the chair tipped over. (R1) was already standing because I had just pulled up her pants and she turned and sat before I could lock the chair. The chair tipped over and she went down so quick. I did not see if she hit her head or not, but she said she did. She had a skin tear on her elbow and on her shin or calf. She was always a one assist for transfers. I didn't use a gait belt because she didn't want me to put it on her. She refuses it all the time. She complained of a lot of pain after the fall. She was getting up because she wanted to go to therapy. She said, 'I got to get up for therapy.' On 2/6/26 at 11:15AM, V3 (Registered Nurse/RN) stated, As the CNA was locking the wheelchair (R1) turned and sat on the arm of the chair and the wheelchair tipped over. She had skin tears on her left elbow and 2 or 3 skin tears on her left shin. She said she hit her head, but she didn't have any head injuries. She said she had a headache. She had no changes in her neuro condition. We did neuro checks throughout the day.R1's Progress Notes dated 1/14/26 state, Staff in room transferring resident from recliner to wheelchair, resident turned self with no assistance from staff while staff was locking left wheel, and sat on right edge/wheel of wheelchair, chair tipped over and resident fell flat onto floor. Skin tears to left elbow and left lower legs, cleansed, measured and covered with dressing. No visible head injuries noted, Tramadol given for headache 5/10 per request. MD (Physician) and POA (Power of Attorney) notified, and neuros initiated.On 2/6/26 at 11:30AM, V5 (Physical Therapy Assistant/PTA) stated, She is usually a 1-person moderate assist. She can walk to the bathroom with staff assist. They should always use a gait belt for transfers.R1's Minimum Data Set assessment dated [DATE] shows she has no cognitive impairment. R1's Care Plan dated 10/7/25 states, Resident has decreased ability to transfer self from wheelchair to chair due to decreased mobility, chronic pain, weakness. The interventions include, Instruct resident to lock wheelchair brakes. and Transfer: I Transfer per one assist, inform me of what you are doing, assist me with sitting at side of the bed and apply gait belt. Allow me time to assist with transfer and praise my efforts for a minimum of 15 minutes per day.The facility policy entitled Fall Prevention Program dated 1/2026 states, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which will determine the individual needs of each resident by assessing the risk of falls and implementations of appropriate interventions to provide necessary supervision and assistance devices are utilized as necessary . Fall/safety interventions may include but are not limited to: Transfer conveyances shall be used to transfer residents in accordance with the plan of care. 145062 Page 2 of 2