Imboden Creek Senior Living: Fall Safety Failures - IL
That resident, identified in inspection records only as R4, had a care plan that spelled out exactly what she needed to stay safe: a body pillow on each side of the bed to keep her from rolling out, a bed pad alarm to alert staff if she moved toward the edge, and a bolster pad overlaid on her mattress. She was documented as cognitively impaired and a fall risk. Her medical record showed falls on June 29, July 11, July 24, August 27, September 1, September 15, October 12, October 19, and October 21 of this year.
On October 24, at 2:42 in the afternoon, none of it was there.
No body pillows. No bed alarm. No bolster overlay. The call light was on the floor underneath the bed, out of reach. Inspectors returned to the room just before 3:30 that same afternoon. The interventions were still not in place.
Four days later, on October 28, inspectors came back again. R4 was lying in bed. Still no body pillow at her side. Still no bed alarm. Still no bolster overlay. The call light was on the floor to the left of the bed. R4 was facing the right.
At 11:50 that morning, inspectors were in the room again. This time, one body pillow had appeared, on R4's right side only. The call light still couldn't be located. The bed alarm was still absent. The Director of Nursing was standing in the room during this observation. She confirmed what inspectors could see: one body pillow present, call light not found, no bed alarm on the bed.
The pattern repeated in the room next door.
A second resident, R5, was also documented as cognitively impaired and a fall risk, with falls recorded on July 1 and October 14. Her care plan, updated after the October fall, required a fall mat at the right side of her bed and her call light kept within reach.
On October 24, at 2:48 in the afternoon, the fall mat was not there. The call light was on the floor on the left side of the bed. When inspectors asked R5 where her call light was, she said she didn't know either.
Imboden Creek Senior Living has a written policy on falls and fall risk management, dated March 2018, that states staff will identify interventions tied to each resident's specific risks and causes, and that an interdisciplinary team will implement a resident-centered fall prevention plan for anyone at risk. The policy was not the problem. What happened in those two rooms, across multiple days and multiple visits, suggests the policy had no reliable connection to what staff actually did.
The Director of Nursing's presence in R4's room on October 28 is worth pausing on. She was there. She could see the missing alarm, the single pillow where two were required, the call light that couldn't be found. She confirmed each gap to inspectors. There is no indication in the inspection record that her presence in that room, on that morning, had produced any of the protections that should have been there before she arrived.
R4 had fallen nine times since late June. Her most recent fall before inspectors arrived had been October 21, three days before the first inspection visit. Her call light was on the floor under the bed.
Federal inspectors cited the facility under Tag F689, which covers the obligation to ensure residents receive adequate supervision and assistive devices to prevent accidents. The deficiency was cited at a level of minimal harm or potential for actual harm, with some residents affected. The inspection was completed November 6, 2025.
What the record does not contain is any account of what R4 did on the nights when she needed help and had no way to ask for it.
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 23, 2026 · Our methodology
IMBODEN CREEK SENIOR LIVING in DECATUR, IL was cited for violations during a health inspection on November 6, 2025.
She was documented as cognitively impaired and a fall risk.
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.