Inspection·June 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free of abuse from another resident. This applies to 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. The finding include: The Facility Reported Final Incident Report dated 6/4/25 states, (R1) came up to (R2) and lightly hit her left cheek with an open hand. (R1) does not recall why he did this but stated he did not hit her. (R2) does not recall the incident . On 6/27/25 at 9:14 AM R1 was ambulating in the hallway with his wheeled walker. R1 had slow but steady gait. R1 was dressed in flannel pants, a t-shirt, and tennis shoes. R1 approached nearly everyone he saw in the hallway asking if they had any candy. R1 was slow to respond at times and just looked at the surveyor when spoken to. On 6/27/25 at 10:50 AM, R2 was seated in a reclining wheelchair, placed in front of the bird aviary. R2 startled as the surveyor approached her but then smiled as the surveyor introduced herself. R2 did not answer questions when asked. R2 just smiled. On 6/27/25 at 10:00 AM, V5 (Certified Nursing Assistant/CNA) stated, I was bringing (R2's) roommate out of the room and (R2) was sitting in the hallway with her eyes closed. (R1) was standing over her and he had his hand raised to her and I told him to stop, and he slapped her across the face anyway. It was hard enough that I heard it but there were no red marks on (R2). She kind of jerked/startled - like anyone would do because her eyes were closed and then she held her face. I told him to go to his room and then V4 (Licensed Practical Nurse/LPN) came down and walked him to his room. I have never known (R1) to hit another resident, but he has hit staff before. He walks around the facility, some days he just stays in his room. On 6/27/25 at 10:10 AM V4 (LPN) stated, The girls came up to me right away. They said he just walked up to her and open handed slapped her on the face. It was totally unprovoked. We separated them. I called V1 (Administrator) and she said to do 15 minutes checks on both of them. It was the strangest thing. (R2) can't recall anything. She had no signs of pain, no crying or sadness. When I ask her about it, she just smiles. (R1) just said I don't know. I have never seen him touch another resident. He gets agitated and irritable with staff. He's more difficult if he doesn't know you. The old (R1) is pleasant and friendly and then 2 hours later he can be completely different. He loves snacks and candy. (R1) likes to sit on the couch up front. He doesn't like activities. He likes to get up early in the morning. There was no after effect for (R2). (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 06/27/2025 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)