Arc at Normal

In the surveyor’s words

From the most serious findings on record at Arc at Normal, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 3, 2023

  The failures at this level require more than one deficiency statement. A.) Based on record review and interview the facility failed to supervise a resident with suicidal ideation, failed to implement the facility suicide watch policy and failed to initiate care plan interventions after R1 verbalized intentions of killing R1's self. Theses failures resulted in R1 continuing to experience thoughts of self harm and then attempting to strangle R1's self with call light and bed control cords. These failures affect one (R1) of five residents reviewed for accidents in a sample list of 31 residents. […]

• Actual harm, isolatedF686Jun 22, 2026

  Based on interview and record review, the facility failed to prevent a pressure ulcer from developing by failing to implement pressure relieving interventions for one (R2) resident and failed to complete pressure ulcer treatments as ordered for two (R2, R3) residents reviewed for pressure ulcers in the sample list of 14. This failure resulted in R2 developing a Deep Tissue Injury to the Right Heel.Findings include:1) R2's Care Plan (undated) documents R2's diagnosis of History of Ischemic Attack (TIA), Cerebral Infarction, Type 2 Diabetes Mellitus, Difficulty Walking, Communication Deficit, Reduced Mobility and Protein-Calorie Malnutrition. […]

• Actual harm, isolatedF684Jun 13, 2025

  Based on interview and record review, the facility failed to obtain medical evaluation and treatment following a resident's fall. This failure resulted in R2 experiencing aches, sharp pains, and a significant decline in cognitive, continence, and ambulatory status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Census Detail dated [DATE] documents R2 was admitted to the facility [DATE], hospitalized from [DATE] through [DATE], re-admitted to the facility [DATE], and expired [DATE]. R2's Medical Diagnoses List dated [DATE] documents R2 had health conditions upon her admission including Malnutrition, History of Transient Cerebral Ischemia, and Chronic Kidney Disease. […]

• Actual harm, isolatedF697Jun 13, 2025

  Based on interview and record review, the facility failed to manage new onset pain for a resident after a fall. This failure resulted in R2 experiencing aches, sharp pains, low oxygen levels, and a significant change in cognitive status. R2 was one of three residents reviewed for accidents on a sample list of three. Findings include: R2's Nursing Notes dated 4/12/25 at 3:25 AM, documents R2 experienced a fall in her room while ambulating with her walker. A subsequent note at 3:27 AM documents R2 was complaining of an achy pain with a numerical value of 2 or 3 out of 10 which was a new onset for R2. R2's Nurses Note dated 4/13/25 at 5:59 PM, documents R2 was complaining of increased sharp pain of her right hip. […]

• Actual harm, isolatedF684May 20, 2025

  Based on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for physician orders from a total sample list of 103 residents. This failure resulted in R1 being hospitalized with high ammonia levels that could have resulted in permanent harm. Findings include: R1's undated diagnosis sheet includes the following diagnoses: unspecified convulsions, alcohol dependence with alcohol-induced persisting dementia, fracture of right acetabulum, fracture of rib, malnutrition, fracture of anterior wall of right acetabulum, traumatic subarachnoid hemorrhage with loss of consciousness, and diabetes. The facility provided admission/discharge report documents that R1 was admitted to the facility on [DATE]. […]