Inspection visit

Health inspectionNovember 20, 2024

IMBODEN CREEK SENIOR LIVINGCMS #1459457 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of resident to resident verbal abuse to the Abuse Coordinator for two of three residents (R23 and R29) reviewed for Abuse in a sample list of 34 residents. Findings include: The facility policy titled Abuse Prevention, dated 8/16/19, documents employees are required to repot any incident, allegation, or suspicion of crime or potential abuse, neglect or misappropriation or property they observe, hear about, or suspect to the Administrator. R23's Minimum Data Set (MDS), dated [DATE], documents R23 as severely cognitively impaired. R29's Minimum Data Set (MDS), dated [DATE], documents R29 as severely cognitively impaired. R23's Nurse Progress Note, dated 8/27/24 at 1:46 PM, documents, During lunch, (R23) started to cry and wanted to leave the dining room. Upon trying to leave (R23) ran into another resident's (R29)wheelchair. The two resident's (R23, R29) started yelling at each other. Staff intervened, (R23) asked to be brought to lobby. (R23) was crying in the lobby. Will continue to monitor. On 11/18/24 at 1:00 PM, V14, Director of Operations, confirmed the other resident involved in R23's resident to resident incident on 8/27/24 is R29. V14 stated V2, Director of Nurses (DON), called V16, Licensed Practical Nurse (LPN), this morning (11/18/24) to obtain a statement of what happened. On 11/18/24 at 3:40 PM, V1, Administrator, stated any allegation of abuse should be reported to the Abuse Coordinator. V1 stated V16 Licensed Practical Nurse (LPN) should have reported the incident between R23 and R29 to the Abuse Coordinator. V1 stated once an allegation is reported to the Abuse Coordinator, then the facility can begin an investigation to determine if the allegation of abuse is substantiated or not. V1 stated if the allegation is not reported to the Abuse coordinator, then there is no investigation and the incident would not get reported to the State Agency. V1, Administrator, stated she was not aware of this incident until 11/18/24. On 11/19/24 at 12:45 PM, V16, Licensed Practical Nurse (LPN), stated R23 was self propelling out of the dining room when her wheelchair got caught on R29's wheelchair. V16 stated R29 was sitting at her dining room table located by the door to the dining room. V16, LPN, stated R23 and R29 began yelling at each other. V16, LPN, stated R23 was having behaviors earlier in the day also. V16, LPN, stated They (R23, R29) weren't hitting each other or anything. They (R23, R29) were yelling at each (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 9 Event ID: 145945 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm other. V16, LPN, stated V16 should have reported this incident to V1, Administrator, when it occurred. V16, LPN, stated V16 saw this incident as a behavior on R23's part, and charted R23's behaviors. V16, LPN, stated V16 could see how it could be considered as something that should have been reported as an allegation of abuse between R23 and R29. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 2 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide weight management services for residents experiencing unplanned weight loss for two of three residents ((R13, R69) reviewed for weight loss on the sample list of 34 residents. Residents Affected - Few Findings include: R13's medical record documents on 11/1/2024 at 10:04 PM a weight of 104.4 pounds, and on 10/9/2024 at 08:06 AM a weight of 114.5 pounds. That is a documented weight loss of 10.1 pounds or a weight loss of 9.1% in a month. There was no documentation the physician was notified. R69's medical record documents on 11/1/2024 at 10:04 PM a weight of 84.0 pounds and on 10/28/2024 at 07:41 AM a documented weight of 97.5 pounds. This is a documented weight loss of 13.5 pounds which equals a loss of 8.6%. There was no documentation the physician was notified. R69's medical record documents on 11/6/2024 at 7:17 PM, R69 was transported and admitted to the hospital. The medical record documents on 11/16/2024 at 8:54 PM, R69 was re-admitted to the facility with a PEG (Percutaneous Endoscopic Gastrostomy) tube in place for continuous feeding. On 11/17/24 at 09:10 AM, R69 stated R69 returned from the hospital last night (11/16/24). R69 stated no one weighed him upon the return from the hospital. On 11/18/24 at 11:25 AM R69's medical record does not document an admission weight from 11/16/2024 at 8:54 PM re-admission. On 11/20/2024 at 12:19 PM, V1, Administrator, stated the nursing staff obtain the weights and input them into the medical record. V1 stated, If there is a significant weight change, the nursing staff should obtain a new weight, if the weight change is verified the nursing staff is to notify the doctor and the Dietician. V1 stated the IDT (interdisciplinary team) reviews weight loss and gains monthly and notifies the doctor and Dietician if not already done by nursing staff. On 11/19/24 12:47 PM, V2, Director of Nursing, stated the doctor and Dietician are to be notified of weight loss 5% or more. The Dietician is to respond within 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 3 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to attempt nonpharmacological intervention prior to implementing psychotropic medications, failed to identify target behaviors for the use of psychotropic medications, and failed to assess use of psychotropic medications for one resident (R6) of eight residents reviewed for Psychotropic medications in a sample list of 34. Findings include: The Facilities policy Psychotropic Medication Use, revised December 2016, documents psychotropic medications will generally only be considered if the following conditions are met: The behavioral symptoms present a danger to the resident or others; Behavioral interventions have been attempted and included in plan of care, except in an emergency. Pertinent non-pharmacological interventions must be attempted, unless contraindicated. R6's Medication Administration Record (MAR) for November 2024 includes the following orders for psychotropic medications: Quetiapine 25 milligrams, give 0.5 tablet twice a day for anxiety. On 11/19/24 01:37 PM, V2 (Director of Nursing) and V24 (Clinical Nurse) stated they were unable to find any behavior tracking or behavior notes for R6. On 11/19/24 at 1:32 PM, R6 stated she is not totally sure what medications R6 takes, because the staff does not talk to her when medications change. On 11/19/24 10:47 AM, R6's care plan, initiated 7/11/2024, does not contain psychotropic medication interventions or non-pharmacological interventions for anxiety. The same care plan does not document anxiety or mood disorders. On 11/19/24 1:15 PM, R6's Medical Diagnosis report documents a diagnoses of Unspecified Dementia without behavioral disturbance, psychotic disorder, mood disorder or anxiety. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 4 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to properly label medications for three residents (R5, R49, R67) out of four residents reviewed for medication administration in a sample list of 34 residents. Findings include: The facility policy titled Labeling of Medication Containers, revised April 2007, documents all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for individual drug containers shall include all necessary information, such as: resident name, physician name, directions for use and expiration date. 1.) R5's Physician Order Sheet (POS), dated November 2024, documents a physician order for Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 unit/milliliter (ml) give one drop in Left eye six times per day, Hydrocortisone External Cream 1 % apply topically to skin around Left Eye three times per day, and Fluticasone Furoate Aerosol Powder Breath Activ 50 micrograms (MCG)/actuation (ACT) daily. On 11/18/24 at 8:12 AM, V10, Licensed Practical Nurse (LPN), administered R5's Fluticasone Furoate 50 micrograms (mcg) inhaler that did not have a label, resident name, or open date documented on R5's inhaler. V10, LPN, administered R5's Polymyxin B-Trimethoprim eye drop to R5's Left eye that did not have a resident label on the bottle of eye drops. V10, LPN, administered R5's Hydrocortisone cream 1% to R5's Left periorbital area that did not have a label with administration instructions. On 11/18/24 at 8:20 AM, V10, Licensed Practical Nurse (LPN), stated R5's Fluticasone Furoate 50 microgram (mcg) inhaler, Polymyxin eye drops and Hydrocortisone cream were not labeled and did not have a date indicating when they had been opened. 2.) R49's Physician Order Sheet (POS), dated November 2024, documents a Physician order starting 11/3/24 for Humulin N 100 UNIT/ML per sliding scale. On 11/18/24 at 11:25 AM, V9, Licensed Practical Nurse (LPN), administered R49's Humulin N 6 units from an Insulin pen preprinted with 'Humulin N-100', with no resident label and no open date written on Insulin pen. On 11/18/24 at 11:30 PM, V9, Licensed Practical Nurse (LPN), stated R49's Insulin pen was not labeled with R49's name, medication, or administration directions. V9, LPN, stated there was no open date written on R49's Insulin pen, so there was no way to tell when R49's Humulin-N 100 Insulin had been opened. 3.) R67's Physician Order Sheet (POS), dated November 2024, documents a physician order starting 9/29/24 for Memantine 100 milligrams (mg) twice daily at 8:00 AM and 4:00 PM. This same POS documents a physician order starting 10/7/24 for Donezepil 10 mg daily at 4:00 PM. R67's Medication Administration Record (MAR), dated November 2024, documents R67 has been administered Memantine 100 mg twice daily from 11/1/24-11/18/24 and Donezepil 10 mg daily from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 5 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0761 11/1/24-11/18/24. Level of Harm - Minimal harm or potential for actual harm On 11/18/24 at 4:18 PM, V11, Licensed Practical Nurse (LPN), administered R67's Memantine 100 milligrams (mg) and Donezepil 10 mg. V11 removed R67's Memantine 100 mg and Donezepil 10 mg pill cards from the medication cart while stating, These labels say to give at bedtime but the Medication Administration Record (MAR) says to give them at 4:00 PM. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 6 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 69 residents residing in the facility. Findings include: On 11/19/24 at 2:30 PM, V1 provided V15's employee file. The file contained a documented position offer to V15 as the Dietary Manager. The position offer letter documents that in this role, V15 will be required to manage all aspects of the Dietary department. This includes regulatory oversight in regard to local, state, and federal requirements as they pertain to safe food handling. The same document documents V15 must enroll and begin the Dietary Manager Course. On 11/19/24 at 2:30 PM, V1, Administrator, provided V15's employee file. V15's initial application documents V15 was hired on 7/12/2024 as the CDM (Certified Dietary Manager). On 11/18/24 at 11:10 AM, V15, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 11/18/24 at 11:15 AM, V13, Regional Dietary Manager, stated V15 is the Dietary manager of the facility. On 11/18/24 at 11:15 AM, V15 stated V15 is the Dietary manager. V15 stated V15 is not a Certified Dietary Manager. On 11/18/24 at 11:20 AM, V27 stated V27 is the [NAME] and V15 is the Dietary manager. On 11/19/24 at 10:15 AM, V15 stated V15 is the Dietary manager. V15 stated V15 is not a Certified Dietary Manager. V15 stated V15 is enrolled in Dietary Management courses that started September 2024, unsure of exact date. V15 stated V15 has not completed the Dietary Manager course at this time. The facility Resident Census and Conditions of Residents report, dated 11/17/24, documents 69 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 7 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to provide timely meals and without serving an evening snack. This failure has the potential to affect all 69 residents in the facility. Findings include: On 11/18/24 at 11:30AM, during resident council meeting, R18, R34, and R37 stated breakfast is served closer to 9AM, and an evening snack has not been offered for the past two to three months. On 11/19/24 at 10:15AM, V15, Dietary Manager, stated meal times are 8AM, 12PM, and 5PM. V15 stated the Dietary department provides snacks in the nutrition room (located off the common area) every evening. V15 stated the snacks are available to staff to pass out for resident consumption after the kitchen is closed. On 11/20/24 at 12:15PM, R57 stated R57 eats in R57's room. R57 had not been served lunch at this time. R57 stated R57 usually receives breakfast tray around 9AM and dinner at 6PM, R57 stated was not aware of snacks being available to residents in the evening. The facility Frequency of Meals Policy, revised July 2017, documents the following: Each resident shall receive at least three meals daily. There will not be more than a fourteen (14) hour span between the evening meal and breakfast. Nourishing snacks will be available for residents who need or desire additional food between meals. Evening snacks will be offered routinely to all residents. Residents will be offered nourishing snacks if the snacks if the time span between the evening meal ant the next day's breakfast exceeds fourteen (14) hours. The facility Resident Census and Conditions of Residents report, dated 11/17/24, documents 69 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 8 of 9 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement an antibiotic stewardship program by failing to assess criteria for determining an infection for one of one residents (R9)reviewed for antibiotic stewardship in the sample of 34 residents. Residents Affected - Few Findings include: The Antibiotic Stewardship policy, dated December 2016, states, the purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. R9's Electronic Medical Record documents R9 receives Hospice services. A Communication Note with Physician, dated 11/14/24, by V28, Licensed Practical Nurse, documents the following: Hospice Certified Nursing Assistant concerned with resident (R9) confusion. Resident confused at times. Antibiotic to begin for urinary tract infection (UTI) and fluids encouraged. R9's Physician Orders (November 2024) documents an order, dated 11/14/24, for Bactrim DS(antibiotic) 800-160 milligram by mouth two times a day for an infection for 10 days. R9's Medical Record fails to document a McGeer Criteria for Infection Surveillance Checklist was completed, whether any testing was done to confirm the infection, and whether cultures were obtained. On 11/19/24 at 1:30 PM, V2, Director of Nursing, stated the facility uses McGeer Criteria for infection surveillance. On 11/19/24 at 11:45AM, V24, Clinical Nurse, stated the facility does not have any supporting documentation/labs for R9's antibiotic use. V24 stated, 'Hospice said it (antibiotic) was for an UTI due to [R9] being confused.' The facility Resident Census and Conditions of Residents report, dated 11/17/24, documents 69 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145945 If continuation sheet Page 9 of 9

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0801GeneralS&S Fpotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0809GeneralS&S Fpotential for harm
F809 - Frequency of Meals
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.

FAQ · About this visit

Common questions about this visit

What happened during the November 20, 2024 survey of IMBODEN CREEK SENIOR LIVING?

This was a inspection survey of IMBODEN CREEK SENIOR LIVING on November 20, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at IMBODEN CREEK SENIOR LIVING on November 20, 2024?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·November 20, 2024