Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on observation, interview, and record review, the facility failed to notify the Power of Attorney/family
of a stage three pressure ulcer for one (R3) of three residents reviewed for pressure ulcers in a sample of
three.
Findings include:
Facility Skin Condition Assessment and Monitoring- Pressure and Non-Pressure, last revised 6/2018,
documents The purpose is to establish guidelines for assessing, monitoring and documenting the presence
of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are
implemented.
Facility Pressure Injury and Skin Condition Assessment, last revised 1/2018, documents Each resident will
be observed for skin breakdown daily during care and on assigned bath day by the CNA/Certified Nurse
Aide. Changes shall be promptly reported to the charge nurse who will perform the detailed assessment. At
the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending
physician will be notified.
R3's Treatment Administration Record/TAR, dated 10/1-10/31/23, has an order dated 10/7/23 for R3's right
heel pressure ulcer.
R3's 10/7/2023 Weekly Skin Observation report documents Resident has a new skin concern. Type of skin
concern: open area with bloody discharge. Located to Right heel - open area, approximate 4 x
2.5cm/centimeters. Treatments include cleansed with wound cleaner, applied collagen pad, and covered
with bordered bandage. Resident does not complain of pain, interventions include Pain Assessment
completed. Family was notified of new condition on ___ (blank). New orders. This form has no
documentation R3's family/legal representative/POA (Power of Attorney) was notified.
On 11/15/23 at 10:50am, V13 (R3's POA) stated I know (R3) has wounds occasionally, but I didn't know he
had one for the past five weeks on his heel. I live in Texas, at one point I was told he had a wound on his leg
not his heel, and I would expect to be notified.
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 3
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
11/15/2023
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)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to follow their abuse policy and report a bruise of unknown
origin to the abuse coordinator and Power of Attorney/family for one (R1) of three residents reviewed for
abuse in a sample of three.
Findings include:
Facility Abuse Prevention and Reporting-Illinois, last revised 10/2022, documents Employees are required
to report any incident to the administrator immediately. Injuries of Unknown Source: An injury should be
classified as an injury of unknown source when both of the following conditions are met: The source of the
injury was not observed, or the source of the injury could not be explained by the resident; and the injury is
suspicious because of the location of the injury. The person gathering facts will document the injury, and
notification to the resident's responsible party. The (state) agency will be notified.
Facility Skin Condition Assessment and Monitoring, last revised 6/2018, documents Bruises: A bruise is an
impact site on the skin's surface over subcutaneous or deeper tissues. On the skin's surface, bruises
undergo progressive color changes before they fade away. 0-2 days: red, swollen, tender; 2-5 days: blue;
5-7 days: green.
R1's medical record documents R1 was admitted on [DATE], went to the hospital 11/6/23, returned
11/11/23, and on 11/12/23 R1 went back to the hospital where he is currently.
R1's Weekly Skin Observation, dated 11/3/23, documents (R1) has a new skin concern. Type of skin
concern: Bruising. Located to Right shoulder (front) - 6.5cm x 5.5cm/centimeters dark purple bruising,
Other (specify) - right inner armpit area, 16 cm x 7.5 cm dark purple bruising, Left elbow - 4 cm x 5 cm dark
purple bruising. MD was notified of new condition on 11/03/2023, family was notified of new condition on
_________(blank).
On 11/14/23 at 2:35pm, V1 (Administrator) said I am not aware of any bruising of unknown origin to (R1). I
am the abuse coordinator and I have given you all the abuse/investigations I have done (no investigation for
R1's bruising). The staff are to report to me and if I am not available, they report to their nurse or other
management. I have not been told anything of any concerns with (R1) having bruising.
On 11/14/23 at 3:38pm, V10 (Licensed Practical Nurse/LPN) stated I made a skin report on (R1) as just an
assessment, I asked (R1) if he had blood drawn or fell and he said he didn't think so, my abuse coordinator
is the administrator, and I did not know I needed to notify the administrator of unknown bruising or injury of
unknown origin. I did not notify the family and I should have.
On 11/14/23 at 3:50pm V9 (R1's Power of Attorney/family) stated I was not notified of any bruising to (R1)
on 11/3/23. (R1) went into the hospital on [DATE] so I am not sure where the bruising would have come
from prior to the hospital. I was not notified and if there were any concerns with abuse I would like to know
and be notified.
On 11/15/23 at 11:15am V1 (Administrator) stated Once I found out about the concern yesterday on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145062
If continuation sheet
Page 2 of 3
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
11/15/2023
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)
F 0609
(R1), I called the nurse and educated her, and reported it to the (state). I am investigating this.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145062
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
FAQ · About this visit
Common questions about this visit
What happened during the November 15, 2023 survey of ARC AT STREATOR?
This was a inspection survey of ARC AT STREATOR on November 15, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARC AT STREATOR on November 15, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.