Imboden Creek Senior Living
IMBODEN CREEK SENIOR LIVING in DECATUR, IL — inspection on November 13, 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
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 R1's, R7's, R10's, and 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 R1's, R7's, R10's and 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 R1, R7, R10, and 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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