Imboden Creek Senior Living

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on interview and record review, the facility failed to timely notify the physician of a resident fall for one of four residents (Resident R9) reviewed for falls in the sample list of eleven residents. Resident R9's Nurse Progress Note dated 10/18/25 at 5:10 AM documents Resident R9 was found on the floor. This same note documents staff assessed Resident R9 with no injuries and Resident R9 denied pain. This same note documents staff assisted Resident R9 back to bed and then informed V33 Licensed Practical Nurse (LPN), Resident R9's nurse. This same note documents V33 LPN then assessed Resident R9 in her room with no findings and no obvious injuries.Resident R9's Progress Note dated 10/18/25 at 7:14 AM documents Resident R9 had swelling to her Right Leg from Hip to Knee noted when staff assisted Resident R9 to get dressed for the day. This same note documents Resident 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.Resident R9's Progress Note dated 10/18/25 at 5:53 PM documents Resident R9 was sent to the emergency room to be evaluated for pain and swelling to her Right Leg.Resident 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 Resident 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 Resident R9 had fallen earlier that morning. V17 LPN stated V29 CNA came to inform her around 7:15 AM that Resident R9's Right Leg was swollen and Resident R9 was complaining of pain. V17 LPN stated she assessed Resident R9 to find that Resident R9 was complaining of Right Leg/Right Knee pain. V17 LPN stated Resident 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 Resident R9's Right Leg.

V17 LPN stated she administered Acetaminophen for pain and applied an ice pack to Resident 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 Resident R9's knee because she was never informed that Resident 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 Resident R9's unwitnessed fall to

the next shift, nursing management, V19 Physician nor V40 (Resident R9's) Power of Attorney (POA). V2 DON stated Resident 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Imboden Creek Senior Living

180 West Imboden Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**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 (Resident R1) reviewed for death in the sample list of eleven residents.Findings include: Resident R1's Electronic Medical Record (EMR) documents Resident R1 passed away at the facility on [DATE REDACTED]. The facility video camera footage of Resident R1's room door showed V8, V10, V21, and V26, Certified Nurse Aides (CNAs), in Resident 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 Resident R1's room at 10:36 AM and exiting at 10:44 AM. On [DATE REDACTED] 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 Resident R1's body from the floor back to her bed using a total body mechanical lift. On [DATE REDACTED] at 12:00 PM, V8, Certified Nurse Aide (CNA), stated V8, V10, V21, and V26, CNAs, provided post-mortem care and transferred Resident 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 Resident R1's body or environment. On [DATE REDACTED] at 12:10 PM, V21, Certified Nurse Aide, stated V8, V10, V21, and V26, CNAs, provided post-mortem care and transferred Resident 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 Resident R1's body after she passed away from the floor to the bed. V21, CNA, stated V3, Resident R1's family, asked the staff to get (Resident R1) cleaned up, so the staff abided. V21, CNA, stated if they (V8, V10, V21, V26) had known to not touch Resident R1's body or environment, they would not have messed with anything.On [DATE REDACTED] at 12:15 PM, V14, Licensed Practical Nurse (LPN), stated V14 called Emergency Medical Services (EMS) and the Coroner's office for Resident R1 on [DATE REDACTED]. 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 Resident 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 REDACTED] at 3:25 PM, V6, Coroner, stated he received a call from the facility on [DATE REDACTED], informing him of Resident R1's death. V6 stated V6 arrived at the facility and was able to view Resident R1's body. V6 stated he took pictures of Resident R1's body, which is part of the normal procedure. V6 Coroner stated Resident R1 was laying on her bed with clean sheets. V6 stated the sheet was covering Resident 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 Resident 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 Resident R1's death. V6 Coroner stated, In a case like this, (Resident R1's) body and the environment (Resident 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 Resident R1's body after she expired on [DATE REDACTED] at 9:45 AM. On [DATE REDACTED] 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Imboden Creek Senior Living

180 West Imboden Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED], 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 REDACTED], V1, Administrator, stated training began on location and identification of code status on [DATE REDACTED] 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 REDACTED]. On [DATE REDACTED], V25, COO, stated he provided the training to the facility management staff on the evening of [DATE REDACTED]. V25, COO, stated V1, Administrator, V23, Regional Clinical Nurse, and V25, COO, started training the facility direct care staff on the evening of [DATE REDACTED] and have continued training with each new shift. V25 stated the trainings for direct care floor staff were completed on [DATE REDACTED]. 4. The facility has incorporated effective CPR procedures for those residents who have chosen to be fully resuscitated in case of emergency. On [DATE REDACTED], V25, COO, stated the facility has updated their CPR policy. On [DATE REDACTED], 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 REDACTED] to discuss the facility change of condition assessment and initiation of CPR and to review policies and procedures. On [DATE REDACTED], V1, Administrator, stated all required members of the QAPI team attended the facility QAPI meeting

on [DATE REDACTED]. 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 REDACTED] 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 REDACTED]. The facility revised the abatement plan four times between [DATE REDACTED] initial version and three subsequent versions on [DATE REDACTED]. The fourth version submitted on [DATE REDACTED] was approved on [DATE REDACTED].

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Imboden Creek Senior Living

180 West Imboden Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

1. 3. Resident R4's MDS, dated [DATE REDACTED], documents Resident R4 as not cognitively intact.

Level of Harm - Minimal harm or potential for actual harm

Resident R4's Fall Risk Evaluation, dated 7/24/25, documents Resident R4 is a fall risk.

Residents Affected - Some

Resident R4's medical record documents Resident 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. Resident R4's Care Plan, dated 7/24/25, documents Resident R4 is to have a body pillow on each side of the bed to prevent Resident 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, Resident 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 Resident R4's reach, with Resident R4 stating Resident 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, Resident R4 remained lying in bed, no bed pillow was present at Resident 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 Resident R4 facing the right side of the bed.

On 10/28/25 at 11:50 AM, Resident R4 was in bed with only one body pillow present on Resident 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 Resident R4's bed.

2. 4. Resident R5's MDS, dated [DATE REDACTED], documents Resident R5 is not cognitively intact.

Resident R5's Fall Risk Evaluation, dated 10/2/25, documents Resident R5 is a fall risk. Resident R5's medical record documents Resident R2 has fallen on 7/1/25 and 10/14/25. Resident 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 Resident R5's room and the call light was on the floor on the left side of the bed and not in reach. Resident R5 stated Resident 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Imboden Creek Senior Living

180 West Imboden Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Imboden Creek Senior Living

180 West Imboden Decatur, IL 62521

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Designate a qualified infection preventionist to be responsible for the infection prevent and control program

in the nursing home.

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.

Event ID:

Facility ID:

If continuation sheet