Health inspection·November 13, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders to use and clean a Continuous Positive Airway Pressure (C-PAP) machine and/or a Bilevel Positive Airway Pressure (BI-PAP) machine for four (R1, R7, R10, R11) residents and failed to obtain and monitor vital signs for three (R1, R10, R11) residents using C-PAP/BI-PAP machines. This failure affects four of four residents (R1, R7, R10, R11) reviewed for Oxygen use in a sample list of eleven residents. Findings include:1.R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact.R1's Hospital Record, dated 10/2/25, documents R1 utilizes Oxygen per nasal cannula at 2 Liters (L)/nasal cannula (NC). This same record documents R1 has his own C-PAP (Continuous-Positive Airway Pressure) machine.R1's Physician Order Sheet (POS), dated October 2025, does not document a physician order for R1 to wear C-PAP. R1's Nurse Progress Note, dated 10/2/15 at 1:05 PM, documents R1 was using Oxygen at 2 L/NC. This same progress note documents R1 uses a C-PAP at night for Sleep Apnea.R1's Electronic Medical Record (EMR) does not document R1's Oxygen saturation levels or respirations on 10/3/25-10/9/25 and 10/11-10/13/25. On 11/12/25 at 9:40 AM, V3 (R1's family member) stated the facility staff did not obtain or monitor R1's respiratory vital signs including oxygen saturation and respirations. V3 stated R1 had his own C-PAP machine that was brought into the facility from home. V3 stated the facility staff did not clean or ensure R1's C-PAP settings are correct.2. R10's undated Face Sheet documents R10 admitted to the facility on [DATE]. This same Face Sheet documents medical diagnoses as Obstructive Sleep Apnea, Pigmentary Retinal Dystrophy, Bilateral Absolute Glaucoma, Atrial Fibrillation and Lack of Coordination.R10's Minimum Data Set (MDS), dated [DATE], documents R10 as cognitively intact.R10's Care Plan, initiated 3/5/25, does not include a focus area, goal, nor interventions for the use of R10's CPAP machine. R10's Physician Order Sheet (POS), dated November 2025, does not document any physician orders for R10 using a Continuous Positive Airway Pressure (C-PAP). This same POS does not document filling, cleaning or monitoring of R10's C-PAP machine/use.R10's Electronic Medical Record (EMR) documents R10's Oxygen Saturation was obtained on 9/11/25, 9/19/25, 10/2/25, 11/6/25 and 11/11/25. The facility is not able to provide any other documented Oxygen Saturation levels for R10. R10's Electronic Medical Record (EMR) documents R10's Respirations were documented on 9/3/25, 9/11/25, 9/19/25, 10/2/25, 11/4/25 and 11/11/25. The facility is not able to provide any other documented Respiration levels for R10. On 11/13/25 at 1:20 PM, R10's C-PAP machine was sitting on the bedside dresser next to R10's bed. R10's C-PAP tubing was laying over her machine with the mask directly touching the top of her dresser. R10's C-PAP tubing was not contained in a bag. R10 stated she owns her C-PAP machine. R10 stated the staff do not clean her machine. R10 stated she is unaware of what the setting are due to I am blind. I can't see the settings. R10 stated she relies on staff to make sure the settings are correct and to clean her C-PAP machine. R10 stated the staff do not obtain her Oxygen saturation level or respirations regularly. 3. R11's undated Face Sheet documents R11 admitted to the facility on [DATE]. This Residents Affected - Some Page 1 of 3 145945 145945 11/13/2025 Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some same Face Sheet documents medical diagnoses as Obstructive Sleep Apnea, Acute Kidney Failure, Diabetes Mellitus Type II, Asthma and Hypertension. R11's Physician Order Sheet (POS), dated November 2025, does not document a physician order for R11 to use Continuous Positive Airway Pressure (C-PAP). This same POS does not document any physician orders for refilling, cleaning or monitoring settings for R11's C-PAP machine.R11's admission Assessment, dated 11/12/25, documents R11 as cognitively intact.R11's Care Plan, intervention dated 11/12/25, instructs staff to monitor for signs and symptoms of respiratory distress and report to the Physician as needed such as Respirations and Pulse Oximetry. R11's Electronic Medical Record (EMR) documents R11's Oxygen saturation was obtained on 11/5/25 and 11/9/25. The facility is unable to provide any further documentation that R11's Oxygen saturation was obtained. R11's Electronic Medical Record (EMR) documents R11's Respirations were obtained on 11/5/25. The facility is unable to provide any further documentation of R11's Respiration levels being obtained. R11's Hospital Record, dated 11/5/25, documents R11 uses CPAP/BIPAP. On 11/13/25 at 3:05 PM, R11's CPAP machine was sitting on her bedside dresser with the tubing placed over the top of the machine. R11 was sitting in her recliner chair next to her bed. R11 stated no one from the facility has assisted her with her CPAP machine. R11 stated V11 (R11's Power of Attorney/POA) has done everything with R11's CPAP. R11's C-PAP tubing was laying over her machine with the mask directly touching the top of her dresser. R11's C-PAP tubing was not contained in a bag.On 11/13/25 at 3:10 PM, V11 (R11's family) stated her older CPAP machine broke in the hospital so she bought her a new one. V11 stated the facility staff have not done anything' with R11's CPAP machine. V11 stated she has been meaning to clean out the water reservoir but hasn't had the time to do it yet. V11 stated she hoped the settings are right since she programmed it by watching a video. V11 stated the facility knows about R11's CPAP machine because the staff move the tubing around all the time.4. R7's undated Face Sheet documents R7 admitted to the facility on [DATE]. This same face sheet documents medical diagnoses as History of Pulmonary Embolism, Coronary Artery Dissection, Diabetes mellitus Type II, Hypertension, Chronic Heart Failure, Obstructive Sleep Apnea, History of other diseases of the Respiratory System, Nonrheumatic Aortic Valve Stenosis, Presence of Aortocoronary Bypass Graft, Pulmonary Hypertension, Retinal Disorder, Asthma, Respiratory Failure and Acute Cough.R7's Minimum Data Set (MDS), dated [DATE], documents R7 as cognitively intact.R7's Care Plan, intervention dated 7/22/24, instructs staff to encourage the use of CPAP/BIPAP. R7's Physician Order Sheet (POS), dated November 2025, does not document a physician order for the settings/use and cleaning of R7's BIPAP machine.On 11/13/25 at 1:45 PM, R7's BI-PAP machine was sitting on his bedside dresser next to his bed. R7's BI-PAP tubing was laying over his machine with the mask directly touching the top of his dresser. R7's BI-PAP tubing was not contained in a bag. V7 stated the facility staff know R7's BI-PAP is there but never clean it out. R7 stated he has had his BI-PAP for years and is aware of the settings. R7 stated the staff never check the settings or do anything with it. On 11/13/25 at 11:50 AM, V5, Nurse Practitioner (NP), stated R1 was a very sick man with many comorbidities. V5, NP, stated R1 was sent to the hospital on [DATE] and again on 10/14/25 for respiratory distress. V5, NP, stated on 10/14/25, R1 was in severe respiratory distress, R1 stated to V5, NP, that it felt like there was too much air being forced in from his C-PAP. V5, NP, stated the facility should obtain Oxygen saturations and respiration levels of all residents twice daily for any resident using Oxygen and/or C-PAP/Bilevel Positive Airway Pressure (BI-PAP) machines. V5, NP, stated vital signs are one of the first signs of a change in condition. All residents should have appropriate settings for their machines and be followed by preferably a Pulmonologist or at least a general Physician. V5, NP, stated the Certified Nurse Aide (CNA) should report the vital signs to the nurse, who should then report any change of condition 145945 Page 2 of 3 145945 11/13/2025 Imboden Creek Senior Living 180 West Imboden Decatur, IL 62521

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 145945 Page 3 of 3