Imboden Creek Senior Living: CPR Failure Immediate Jeopardy - IL
The deficiency, tagged F0678, was not a paperwork problem. It was a gap between a resident's documented wish to be kept alive and the staff member who would actually have to act on that wish in the seconds after a body went still.
The facility's own plan of correction lays out, in procedural language, what had gone wrong. The Human Resources Director, identified in inspection documents as V28, acknowledged that a new acknowledgment form had to be created, one that new employees would sign to confirm they had been trained on the CPR policy and, specifically, on where in a resident's chart to find their code status. That form did not exist before inspectors arrived.
The Director of Nurses and the Administrator, identified as V2 and V1, were part of the corrective response rather than its architects. The Chief Operating Officer, V25, drove in and personally conducted training for management staff the evening the plan was being assembled. He and the Administrator and a Regional Clinical Nurse then moved through the building shift by shift, training direct care floor staff. That process, according to the Administrator, was completed only after inspectors had already declared the violation.
The facility revised its abatement plan four times. The first version was submitted, then three more followed on subsequent dates before a fourth version was finally approved. That revision cycle, four attempts to describe how the facility would fix a problem serious enough to trigger immediate jeopardy, suggests the initial responses did not satisfy inspectors that the danger had been adequately addressed.
Every resident chart was reviewed, according to the Administrator, to reconcile code status documentation with the physician order sheet and the face sheet, ensuring that any resident who had chosen to be a full code had that information accessible. That review was completed, the Administrator stated, at 9:00 AM on the date it was announced. The facility also updated its CPR policy itself, not just its training on the existing one.
A Quality Assurance meeting was held to formally review the change-of-condition assessment process and CPR initiation procedures. The Administrator stated all required members attended. The Interdisciplinary Team committed to continuing education on change-of-condition assessment and CPR every six months for one year, then annually, and upon hire for any new staff.
What the inspection record does not contain is any account of what prompted the complaint that led inspectors to the facility in the first place. The survey was complaint-driven. Something happened, or someone believed something had happened or nearly happened, that caused a complaint to be filed. The documents released do not describe that event.
What they do describe is a facility where, as of the November inspection date, a resident who had signed paperwork asking to be resuscitated could not be confident that the person who found them unresponsive would know that, or would know what to do about it.
The Administrator said training on locating and identifying code status began on the date specified and will continue with any newly hired staff or staff working on an as-needed basis. Whether that commitment holds past the period of regulatory scrutiny is not something inspection documents can answer. What they record is what was true the day inspectors walked in: the gap was there, and it was serious enough that CMS assigned its highest level of harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imboden Creek Senior Living from 2025-11-06 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 22, 2026 · Our methodology
IMBODEN CREEK SENIOR LIVING in DECATUR, IL was cited for immediate jeopardy violations during a health inspection on November 6, 2025.
The deficiency, tagged F0678, was not a paperwork problem.
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.