Arc At Streator
ARC AT STREATOR in STREATOR, IL — inspection on February 27, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
findings include:R1's current care plan dated 2/6/26 showed R1 was severely cognitively impaired
summary report showed R5 had diagnoses including epilepsy (seizure disorder) and chronic pain.
The report showed the following medication orders for R5:1.Carbamazepine (anticonvulsant drug) 400 mg (milligrams), give one tablet at bedtime daily.2.Phenobarbital (anticonvulsant drug) 97.2 mg, give one tablet at bedtime daily.3.Tramadol (opioid pain medication) 50 mg, give one tablet three times a day for pain.R1's progress notes dated 2/11/26-2/12/26 showed on 2/11/26 at 8:20 PM, V6 (Licensed Practical Nurse/LPN) administered R5's Carbamazepine 400 mg, Phenobarbital 97.2 mg, and Tramadol 50 mg to R1 in error.
The notes showed R1's physician and Poison Control were notified immediately of the error.
Per recommendation of Poison Control and the physician, R1 was to remain in the facility with orders to closely monitor R1, however, R1's family requested R1 be sent to a local hospital for an evaluation due to the error.
The notes showed R1 was evaluated at the hospital and discharged back to the facility approximately eight hours later in stable condition.On 2/27/26 at 10:15 AM, V6 (LPN) stated on 2/11/26, she prepared R1 and R5's evening medications by putting each resident's medications in separate medication cups. V6 stated she was abruptly called into another resident's room, so she quickly locked R1 and R5's medications, in their individual cups, in the medication cart, and went to assist the resident. V6 stated when she returned to the medication cart, she grabbed R5's medication cup and administered R5's medications to R1 in error. V6 stated, I was in a hurry. I didn't check to make sure I had the right medications for (R1). V6 stated, (R1) was sleepy when he left in the ambulance but that was normal for him at that time of the day.
His mentation had not changed.On 2/27/26 at 9:40 AM, V5 (R1's Physician) stated, While (R5's) medication could have caused (R1) to be sedated, this incident is something we could have monitored in the facility. (R1) did not need to go to the hospital. We only sent him out because his family said to.
They observed him for a while in the hospital and sent him back.On 2/27/26 at 12:07 PM, V3 (Assistant Director of Nursing) stated nurses are to double check medications before administration to verify the medication is the right drug, right patient, right dose, right time, and right route. V3 stated nurses are to administer medications to each resident, immediately after preparing their medications.
The facility's Medication Administration policy dated January 2026 showed, Medications must be administered in accordance with physician's order, e.g., the right resident, right medication, right dosage, right route, right time.
Medications may not be pre-poured, e.g., only prepare and administer medications for one resident at a time.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.