Imboden Creek Senior Living
Inspection Findings
F-Tag F0695
F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
to the provider. On 11/13/25 at 1:30 PM, V10, Regional Clinical Nurse, stated she made a list of every resident with Oxygen, C-PAP and/or BI-PAP machines, and is researching where the machines came from, what the settings are, and reaching out to V5, Nurse Practitioner, for orders to clean and manage Resident R1's, Resident R7's, Resident R10's, and Resident R11's C-PAP/BI-PAP machines including obtaining vital signs. V10, Regional Clinical Nurse, stated the facility does not have a Respiratory Therapist. V10 stated any resident with a C-PAP/BI-PAP machine should be assessed by a Respiratory Professional to ensure the settings are correct, the machines are being cleaned, and the masks fit properly. V10 stated the facility is currently working on contracting a Respiratory Therapist. On 11/13/25 at 2:30 PM, V1, Administrator, stated all residents who use Oxygen and/or C-PAP/BI-PAP machines should have their respiratory vital signs taken twice daily. V1, Administrator, stated she and V10, Regional Clinical Nurse, have both searched through Resident R1's, Resident R7's, Resident R10's and Resident R11's charts are unable to find any further documentation. V1, Administrator, stated there is no proof that vital signs were obtained. V1, Administrator, confirmed Resident R1, Resident R7, Resident R10, and Resident R11 did not have physician orders for their C-PAP/BI-PAP machines. The facility policy titled C-PAP and Bi-PAP support revised April 13, 2020 documents staff are to review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory status, review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP and EPAP) for the machine. Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. Resident should be NPO for at least 2 hours before using a full-face mask. Monitor the oxygen saturation of the resident. Cleaning will be completed by licensed nurse weekly, utilizing specific instructions from the manufacturer and as indicated on the treatment order. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure, time CPAP was started and duration of the therapy, mode and settings for the CPAP/IPAP/EPAP, Oxygen concentration and flow, if used, how the resident tolerated the procedure, and notify the physician if the resident experiences any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs.
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IMBODEN CREEK SENIOR LIVING in DECATUR, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DECATUR, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from IMBODEN CREEK SENIOR LIVING or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.