Imboden Creek Senior Living
IMBODEN CREEK SENIOR LIVING in DECATUR, IL — inspection on November 6, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, the facility failed to timely notify the physician of a resident fall for one of four residents (R9) reviewed for falls in the sample list of eleven residents. R9's Nurse Progress Note dated 10/18/25 at 5:10 AM documents R9 was found on the floor.
This same note documents staff assessed R9 with no injuries and R9 denied pain.
This same note documents staff assisted R9 back to bed and then informed V33 Licensed Practical Nurse (LPN), R9's nurse.
This same note documents V33 LPN then assessed R9 in her room with no findings and no obvious injuries.R9's Progress Note dated 10/18/25 at 7:14 AM documents R9 had swelling to her Right Leg from Hip to Knee noted when staff assisted R9 to get dressed for the day.
This same note documents R9 had swelling noted to Right Knee, Right Femur, pain noted when Right Leg/Right Hip moved, no redness or warmth noted to Right Leg, pain noted with touch as well.R9's Progress Note dated 10/18/25 at 5:53 PM documents R9 was sent to the emergency room to be evaluated for pain and swelling to her Right Leg.R9's Femur X-Ray report dated 10/18/25 documents impression of acute, displaced fracture of the distal Femoral shaft.
This same report documents there is an acute oblique fracture of the distal Femoral Diaphysis.On 11/4/25 at 12:30 PM V17 Licensed Practical Nurse (LPN) stated she was R9's nurse on 10/18/25. V17 LPN stated she did not get a verbal report from V33 LPN (Night Shift Nurse) that morning because V33 LPN left early. V17 LPN stated V33 LPN had written down on a piece of paper her report to pass to V17 LPN. V17 LPN stated she had no idea that R9 had fallen earlier that morning. V17 LPN stated V29 CNA came to inform her around 7:15 AM that R9's Right Leg was swollen and R9 was complaining of pain. V17 LPN stated she assessed R9 to find that R9 was complaining of Right Leg/Right Knee pain. V17 LPN stated R9's Right Knee was slightly more pink and swollen than her Left Knee. V17 LPN stated there was no bruising or obvious deformity to R9's Right Leg.
V17 LPN stated she administered Acetaminophen for pain and applied an ice pack to R9's Right Knee to reduce the swelling. V17 LPN stated she contacted V19 Physician. V17 LPN stated she tried to find out what had happened to R9's knee because she was never informed that R9 had an unwitnessed fall. On 11/4/25 at 2:10 PM a voicemail message was left for V33 LPN to call for interview. No response received.
On 11/5/25 at 2:00 PM V2 Director of Nurses (DON) stated V33 LPN did not report R9's unwitnessed fall to the next shift, nursing management, V19 Physician nor V40 (R9's) Power of Attorney (POA). V2 DON stated R9's unwitnessed fall should have been reported to all of the necessary people and was not.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Imboden Creek Senior Living
180 West Imboden Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
Ensure services provided by the nursing facility meet professional standards of quality.
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an undisturbed environment following the death of a resident prior to the arrival of the coroner for one of six residents (R1) reviewed for death in the sample list of eleven residents.Findings include: R1's Electronic Medical Record (EMR) documents R1 passed away at the facility on [DATE].
The facility video camera footage of R1's room door showed V8, V10, V21, and V26, Certified Nurse Aides (CNAs), in R1's room following her death at 9:45 AM and prior to V6, Coroner, arriving at the facility.
This same camera footage shows V6, Coroner, entering R1's room at 10:36 AM and exiting at 10:44 AM. On [DATE] at 11:30 AM during observation of facility camera footage, V1, Administrator, stated the staff (V8, V10, V21, V26) CNAs were providing post-mortem care and transferring R1's body from the floor back to her bed using a total body mechanical lift. On [DATE] at 12:00 PM, V8, Certified Nurse Aide (CNA), stated V8, V10, V21, and V26, CNAs, provided post-mortem care and transferred R1 from the floor back to her bed after her death. V8, CNA, stated no one told them (V8, V10, V21, V26) not to mess with R1's body or environment. On [DATE] at 12:10 PM, V21, Certified Nurse Aide, stated V8, V10, V21, and V26, CNAs, provided post-mortem care and transferred R1 from the floor back to her bed after her death. V21, CNA, stated all four CNAs (V8, V10, V21, V26) used a total body mechanical lift to move R1's body after she passed away from the floor to the bed. V21, CNA, stated V3, R1's family, asked the staff to get (R1) cleaned up, so the staff abided. V21, CNA, stated if they (V8, V10, V21, V26) had known to not touch R1's body or environment, they would not have messed with anything.On [DATE] at 12:15 PM, V14, Licensed Practical Nurse (LPN), stated V14 called Emergency Medical Services (EMS) and the Coroner's office for R1 on [DATE]. V14, LPN, stated she did not speak to V6, Coroner, directly, but did speak with the Coroner's office receptionist. V14, LPN, stated she did not remember if she was instructed not to touch R1's body/environment, but was told V6 would either call or come to the facility.
V14, LPN, stated normally if V6, Coroner, has to release the resident's body to the funeral home, and if there is any question, then V6, Coroner, comes to the facility. V14, LPN, stated the staff should not touch the resident's body or environment until the Coroner says it is ok to do so. On [DATE] at 3:25 PM, V6, Coroner, stated he received a call from the facility on [DATE], informing him of R1's death. V6 stated V6 arrived at the facility and was able to view R1's body. V6 stated he took pictures of R1's body, which is part of the normal procedure. V6 Coroner stated R1 was laying on her bed with clean sheets. V6 stated the sheet was covering R1's body up to her shoulders with her head/neck area outside of the sheet. V6, Coroner, stated the room was clean with no medical supplies present. V6, Coroner, stated he was not told by the facility that emergency services were present, that Cardiopulmonary Resuscitation (CPR) was not provided by the facility or the EMS, or that R1 had chosen to be a Full Code. V6, Coroner, stated the facility was told by V6 on the phone that V6 would be out to investigate R1's death. V6 Coroner stated, In a case like this, (R1's) body and the environment (R1) expired in should be left untouched. It is considered a possible crime scene, and no one should tamper with any part of it. V6 stated the facility should not have tampered with R1's body after she expired on [DATE] at 9:45 AM. On [DATE] at 1:00 PM, V1 stated the facility does not have a policy for when staff provide post-mortem care when a resident is considered a Coroner case, but the expectation is for staff to abide by the standard of care. V1, Administrator, stated she will be in-servicing the staff on when to provide post-mortem care.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Imboden Creek Senior Living
180 West Imboden Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
hire staff will be educated prior to the start of their shift either through the onboarding employee hiring process or by V1, Administrator, or V2, Director of Nurses (DON). 2.
All facility direct care personnel have been educated to ensure they are aware of the policy related to change of condition assessment and immediate initiation of CPR and identification of the location the resident's code status is documented. On [DATE], V28, Human Resources Director (HR), stated she provides the training for all new employees. V28 stated there is a new ‘acknowledgement' form that all new employees will be signing which indicates that the employee has been trained on the facility CPR policy and where to find a resident's code status. V28, HR, stated if there are specific questions, then V2, Director of Nurses/Designee, will educate the newly hired staff further. On [DATE], V1, Administrator, stated training began on location and identification of code status on [DATE] and will continue with any new staff hired or staff categorized as ‘As needed.'3.
The facility provided education by V25, Chief Operating Officer (COO), to the facility management staff (V1, Administrator, V2, Director of Nurses, V22, Minimum Data Set/LPN) on the evening of [DATE]. On [DATE], V25, COO, stated he provided the training to the facility management staff on the evening of [DATE]. V25, COO, stated V1, Administrator, V23, Regional Clinical Nurse, and V25, COO, started training the facility direct care staff on the evening of [DATE] and have continued training with each new shift. V25 stated the trainings for direct care floor staff were completed on [DATE]. 4.
The facility has incorporated effective CPR procedures for those residents who have chosen to be fully resuscitated in case of emergency. On [DATE], V25, COO, stated the facility has updated their CPR policy. On [DATE], V1, Administrator, stated every resident chart was reviewed and reconciled with the resident Physician Order Sheet (POS) and face sheet to ensure any resident who chooses to be a ‘Full Code' has that information easily accessible to staff. 5.
The facility held a Quality Assurance Performance Improvement (QAPI) meeting on [DATE] to discuss the facility change of condition assessment and initiation of CPR and to review policies and procedures. On [DATE], V1, Administrator, stated all required members of the QAPI team attended the facility QAPI meeting on [DATE]. V1, Administrator, stated facility staff have reviewed 100% of resident charts to ensure proper orders are in place and appropriate chart identification for advanced directives. V1 stated this was completed on [DATE] at 9:00 AM. V1, Administrator, stated the facility Interdisciplinary Team (IDT) team will continue with reeducation of change of condition assessment, reporting, and initiation of CPR. V1, Administrator, stated this education will be offered every 6 months for one year, annually, and upon hire.The facility presented an abatement plan to remove the immediacy on [DATE].
The facility revised the abatement plan four times between [DATE] initial version and three subsequent versions on [DATE].
The fourth version submitted on [DATE] was approved on [DATE].
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Imboden Creek Senior Living
180 West Imboden Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
- R4's MDS, dated [DATE], documents R4 as not cognitively intact.
R4's Fall Risk Evaluation, dated 7/24/25, documents R4 is a fall risk.
R4's medical record documents R4 has fallen on 6/29/25, 7/11/25, 7/24/25, 8/27/25, 9/1/25, 9/15/25, 10/12/25, 10/19/25, and 10/21/25.
R4's Care Plan, dated 7/24/25, documents R4 is to have a body pillow on each side of the bed to prevent R4 from rolling out of bed, a bed pad alarm placed when in bed, and an overlay of bolster pad onto standard mattress.
On 10/24/25 at 2:42 PM, R4 did not have body pillows on each of her sides, no bed alarm was present, no overlay bolster to mattress was present, and the call light was on the floor under the bed, not within R4's reach, with R4 stating R4 does not know where the call light is located. On 10/24/25 at 3:30 PM, fall interventions continue to not be in place.
On 10/28/25, throughout the morning, R4 remained lying in bed, no bed pillow was present at R4's side while in bed, no bed alarm was present, no overlay bolster to the mattress was present, and the call light was on the floor to the left side of the bed, with R4 facing the right side of the bed.
On 10/28/25 at 11:50 AM, R4 was in bed with only one body pillow present on R4's right side, the call light cannot be located, and no bed alarm was present. V2 DON was present in the room during this observation and stated one body pillow is present, the call light cannot be located, and no bed alarm is present on R4's bed.
- R5's MDS, dated [DATE], documents R5 is not cognitively intact.
R5's Fall Risk Evaluation, dated 10/2/25, documents R5 is a fall risk.
R5's medical record documents R2 has fallen on 7/1/25 and 10/14/25.
R5's Care Plan, dated 10/14/25, documents a fall mat to be at the right side of the bed and to have the call light within reach.
On 10/24/25 at 2:48 PM, a fall mat was not present at the side of the bed in R5's room and the call light was on the floor on the left side of the bed and not in reach. R5 stated R5 does not know where the call light is located.
The facility's Falls and Fall Risk, Managing policy, dated March 2018, documents based on evaluations and current data, staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.
This policy also documents the staff with the Interdisciplinary Team will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk for falls or with a history of falls.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Imboden Creek Senior Living
180 West Imboden Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
date. V1, Administrator, stated the facility will update the Face Sheet binder as soon as possible. V1, Administrator, stated there is not a specific policy for this problem, but the facility is expected to maintain complete medical records, including Advanced Directives for all residents. V1, Administrator, stated the staff should have access to pertinent medical records to provide all necessary cares for all residents. V1 stated there is no policy for medical records being easily accessible for staff but that is the expectation. V1 Stated the facility keeps a Face Sheet binder that had not been up to date and that could cause a delay in emergency care for any resident.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Imboden Creek Senior Living
180 West Imboden Decatur, IL 62521
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to employ an Infection Preventionist who remains onsite.
This failure has the potential to affect all 70 residents residing in the facility.
Findings include:The facility daily midnight roster, dated 8/24/25, documents 70 residents reside in the facility.
The Facility Assessment, reviewed July 10, 2025, documents a member of the team of nursing directors is designated as the certified Infection Preventionist.
Utilizing information exchange in daily report, referral reports, physician orders, pharmacy reports (antibiotic report) and quality measures, nursing directors are able to analyze data and know real time diagnosis and treatment to manage an effective infection control program.
The facility is unable to provide an Infection Preventionist certificate for any employee working onsite.
During standard survey observations on 10/24/25, 10/28/25-10/31/25, 11/4-11/6/25 there was not an Infection Preventionist in the facility. On 10/31/25 at 2:45 PM, V1, Administrator, stated the facility does not have an Infection Preventionist. V1, Administrator, stated corporate does have an Infection Preventionist, but that person is ‘never in the building.' V1, Administrator, stated she is aware the facility should have an Infection Preventionist and is working towards hiring one.
Facility ID: