Imboden Creek Senior Living
IMBODEN CREEK SENIOR LIVING in DECATUR, IL — inspection on September 17, 2025.
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
ordered by the physician. V2 stated nurses are to perform the wound treatments according to physician orders, and if wound treatments are not completed as ordered, the wound would worsen and likely become infected causing the wound to take longer to heal. On 9/17/25 at 11:30am V6, Hospice Nurse, confirmed the hospice documentation does not document a pressure ulcer wound on R1 at time of admission. 2.R2's undated care plan documents an admission date of 12/20/2024, with diagnoses of Parkinson's Disease Without Dyskinesia, Unsteadiness On Feet, Other Symptoms and Signs Involving the Musculoskeletal System, History Of Malignant Neoplasm Of Ovary, Acute Kidney Failure and Dementia. R2's September 2025 Treatment Administration Record documents a physician order for wound/pressure ulcer treatment dated 08/26/2025.
The same document documents the physician order of cleanse sacral wound with normal saline.
Pack gauze soaked in quarter strength bleach water into wound with cotton tipped applicator.
Cover with ABD (gauze) pad.
Change dressing two times a day (8am and 8pm) for Wound Care for 24 days.
This same document documents on September 2,3,4,5,8,9,11,13,14 the 8am treatment was not completed and September 12 the 8pm treatment was not completed. On 09/15/25, R2's medical record documents R2's last skin/wound assessment as completed on 7/28/25. On 09/16/25 at 11:30am, R2's sacral unstageable deep tissue injury (pressure ulcer) wound care was performed by V3, Corporate Nurse, and V7, Licensed Practical Nurse (LPN).
The wound had full-thickness tissue loss with muscle exposed and can be directly seen.
The wound bed and edges are red and inflamed. V7 used bleach solution soaked gauze to pack the undermining around the wound edges, R2 complained of pain during the packing by V7.
On 09/11/2025 at 12:30pm, V2, Director of Nurses (DON), stated R1 and R2 have wounds/pressure ulcers that need treatments.On 9/16/25 at 2:30pm, V2, DON, confirmed nurses are to perform a weekly wound assessment and there are no weekly skin/wound assessments performed by facility nurses for R2 as the Skin/Wound policy states and the treatment administration record for September 2025 documents the treatments were not completed as ordered by the physician. V2 stated nurses are to perform wound treatments according to physician orders, and if wound treatments are not completed as ordered, the wound could worsen and likely become infected causing the wound to take longer to heal.
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