Imboden Creek: Resident Hit During Fan Dispute - IL
The August incident at Imboden Creek Senior Living involved two residents with dementia and cognitive impairments sitting in wheelchairs at the nurse's station when the confrontation erupted. Federal inspectors found the facility failed to protect residents from physical abuse between patients.
R2 began yelling at R3 that "she stole my fan, I'm going to knock her head off," according to the facility's initial incident report dated August 2. The report documented that R3 "was struck with an open hand in a smacking motion by R2."
But staff gave investigators two different versions of what happened next.
Certified nursing assistant V6 told inspectors on September 3 that both residents were sitting in their wheelchairs at the nurse's station when R2 started yelling the fan accusation at R3. "As we were backing (R3) up away from (R2), (R2) reached over and hit (R3) on the shoulder two times with an open hand," V6 stated.
The next day, licensed practical nurse V3 provided a different account. She said the incident happened after dinner and that R2 was "having a bad day." V3 heard R2 say "you stole my fan" to R3, then watched as a nursing assistant tried to pull R2 away from R3.
"R2 made a motion with her arm/hand like R2 was going hit R3 and R2's fingertips grazed R3's shoulder," V3 told inspectors. She insisted R2 had an open hand but "only her fingertips grazed R3."
The conflicting staff accounts highlight ongoing problems between the two residents. R3 asked "what happened" during the confrontation because R2 was yelling, then said "what did I do wrong?" according to V3's statement.
V3 revealed that R2 and R3 had previously been roommates but R3 was moved to another room "because R2 would yell at R3." She described R2 as someone who "can get agitated and yell."
Medical records show both residents suffered from conditions that could contribute to behavioral problems. R2's diagnoses included anxiety disorder, restlessness and agitation, and mild cognitive impairment. Despite these conditions, R2's most recent assessment classified her as "cognitively intact."
R2's care plan, dated August 10, 2024, documented multiple behavioral concerns. She had "the potential to demonstrate verbally abusive behaviors," "poor impulse control," "verbal aggression towards staff and roommate," "behavior problem with roommate," and "potential to demonstrate physical behaviors." The plan also noted dementia, poor impulse control, and anger issues.
R3's medical profile painted a picture of significant cognitive decline. Her diagnoses included cognitive communication deficit, general anxiety disorder, dementia without behavioral disturbances, psychotic disturbances, mood disturbances, and major depressive disorder.
R3's care plan from December 15, 2024, documented "impaired cognitive function related to dementia," communication problems related to dementia, impaired visual function, behavior problems, and major depression.
The facility's own abuse policy, dated August 16, 2019, explicitly prohibited the type of incident that occurred. The policy stated the facility "affirms the right of the residents to be free from abuse" and "prohibits abuse of the residents." It committed to establishing "a resident sensitive and resident secure environment."
The policy specifically addressed resident-to-resident incidents, stating the facility "is committed to protecting the residents from abuse by anyone including other residents."
Federal inspectors found the facility failed to meet this commitment. The violation was classified as causing "minimal harm or potential for actual harm" and affected "few" residents.
The inspection occurred September 5, more than a month after the fan dispute. Investigators reviewed three residents for potential abuse issues from a sample list of 12 residents, finding violations involving one resident.
The case illustrates the challenges nursing homes face when caring for residents with dementia and cognitive impairments who may not understand their actions or remember behavioral interventions. Both residents involved had documented histories of behavioral problems, yet staff appeared unprepared to prevent the physical confrontation.
R3's question during the incident - "what did I do wrong?" - suggested confusion about why R2 was yelling. Her visual impairment, documented in her care plan, may have made it difficult for her to see or understand R2's aggressive approach.
The facility had already recognized the incompatibility between the two residents by moving them to separate rooms due to R2's verbal aggression. But the August incident showed that separation wasn't enough when both residents used common areas like the nurse's station.
The conflicting staff accounts raise questions about training and incident documentation. One staff member described clear physical contact with two open-hand strikes to the shoulder. Another characterized the same incident as fingertips grazing during an attempted swing.
Such discrepancies can complicate efforts to protect vulnerable residents and investigate potential abuse. Clear, consistent reporting becomes crucial when dealing with residents who may not remember incidents or be able to provide reliable accounts due to cognitive impairment.
The incident report was filed August 2, the same day as the confrontation, suggesting staff recognized the seriousness immediately. But the varying descriptions of what actually happened highlight ongoing challenges in documenting and preventing resident-to-resident abuse.
R3 remains at the facility with documented major depression, dementia, and the memory of being yelled at and struck by another resident over a fan she may not have taken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imboden Creek Senior Living from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
IMBODEN CREEK SENIOR LIVING in DECATUR, IL was cited for violations during a health inspection on September 5, 2025.
Federal inspectors found the facility failed to protect residents from physical abuse between patients.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.