Imboden Creek Senior Living: Wound Care Failures - IL
The resident, identified in inspection records as R2, was admitted in December 2024 with Parkinson's disease, dementia, acute kidney failure, and a history of ovarian cancer. By late August 2025, a physician had ordered wound care twice daily, at 8 a.m. and 8 p.m.: cleanse the sacral wound with saline, pack bleach-soaked gauze into the wound cavity using a cotton-tipped applicator, cover with a gauze pad, repeat every twelve hours.
Staff did not complete the morning treatment on September 2, 3, 4, 5, 8, 9, 11, 13, and 14. They missed the evening treatment on September 12. The last documented skin and wound assessment in R2's medical record was dated July 28.
On September 16, a corporate nurse and a licensed practical nurse performed the wound care while inspectors observed. What they found was a wound with full-thickness tissue loss, muscle directly visible, and a red, inflamed wound bed. When the LPN packed the gauze into the undermining around the wound edges, R2 complained of pain.
The Director of Nurses confirmed to inspectors that afternoon that no weekly wound assessments had been completed for R2 as required, and that the treatment record showed the missed treatments. She acknowledged the consequences plainly: if wound treatments are not completed as ordered, the wound could worsen and likely become infected, causing it to take longer to heal.
She had said something similar five days earlier. On September 11, the Director of Nurses told inspectors that both R1 and R2 had wounds that needed treatments.
That was September 11. The wound still had exposed muscle on September 16.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imboden Creek Senior Living from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
IMBODEN CREEK SENIOR LIVING in DECATUR, IL was cited for violations during a health inspection on September 17, 2025.
By late August 2025, a physician had ordered wound care twice daily, at 8 a.m.
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.