Inspection·January 11, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify a resident's Power of Attorney and Physician timely of a resident's refusal to wear a CPAP/Continuous Positive Airway Pressure therapy and failed to notify a resident's Power of Attorney when the CPAP therapy was discontinued for one of three residents (R1) reviewed for CPAP therapy in the sample of four. Findings include: The facility's Medication and Treatment Refusal Policy dated August 2023 states. Incidents related to a resident's refusal of medication and/or treatment must be recorded in resident's medical record. f. The fate and time the physician was notified as well as the physician's response: If resident continually refuses medication and/or treatment, i.e., two or more consecutive times for three days, Administrator and the Attending Physician notified. The facility's Physician-Family Notification-Change in Condition Policy dated August 2023 states, Purpose: To ensure that medical care problems are communicated to the attending physician or authorized designee and family/responsible party in a timely, efficient, and effective manner. Responsibility: Licensed Nursing Personnel/Social Services. Guidelines: The facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: C. A need to alter treatment significantly. The facility's CPAP (Continuous Positive Airway Pressure) Therapy Policy dated November 2023 states, Purpose: Continuous Positive Airway Pressure is used to treat obstructive sleep apnea. The goals of this therapy include improve ventilation; improve quality of sleep, decrease hospitalizations; improve cognitive function; improve oxygen saturation during sleep; decrease work of breathing; and improve lung compliance. R1's Face Sheet documents R1 admitted to the facility on [DATE] with a diagnosis to include but not limited to: Obstructive Sleep Apnea and documents V7 as R1's Power of Attorney for Health Care. R1's Order Summary Report dated 7/31/23-12/31/23 documents orders for: Apply CPAP at bedtime related to Obstructive Sleep Apnea; CPAP Settings at 12; Follow-Up appointment on 12/20/23 at the (Name of Provider) where R1 was followed; and Remove CPAP in the morning related to Obstructive Sleep Apnea. R1's Treatment Administration Record/TAR dated 8/1/23-8/31/23 states, Apply CPAP at bedtime related to Obstructive Sleep Apnea. This same TAR documents R1 refused the CPAP treatment on the following (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 01/11/2024 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)