Health inspection·September 5, 2025

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 notify a family member of an accident for one of three residents (R1) reviewed for resident injury in the sample list of 12. Findings include:R1's undated Diagnoses list includes fracture of other parts of the pelvis, subsequent encounter for fracture with routine healing, Chronic Pain due to trauma, other reduced mobility, unspecified abnormalities of Gait and Mobility, and unsteadiness on feet.R1's Care Plan dated 10/15/24, documents impaired cognitive function or impaired thought processes, impaired decision-making, long-term memory loss, short term memory loss related to age, history of falling, and decreased mobility with an intervention for an alarm when R1 is in the chair related to impulsivity. R1's Fall Risk Evaluation dated 6/13/25, documents R1 is at risk for falls due to intermittent confusion, being chair bound, and requiring use of assistive devices.On 9/3/25 at 9:30 AM V1 Administrator stated on 8/26/25 R1 was observed on the floor on R1's buttocks. V1 stated V3 Licensed Practical Nurse (LPN) found R1 as V3 was walking by and heard yelling so V3 told V4 LPN and V5 Certified Nursing Assistant (CNA). V1 stated R1 had a bruise to her right temple and right arm and a small bruise on her left forearm. V1 stated the family was not notified at that time. On 9/4/25 at 11:15 AM, V4 LPN stated V4 got to the facility around 2:15 PM. V4 stated when V4 walked in she punched the time clock, and another nurse V3 LPN was yelling that R1 was on the floor. V4 stated V4 told another nurse V7 LPN that V4 would go check on R1 for V7. V4 stated V5 CNA came in the room also and R1 was sitting on her buttocks right in front of her wheelchair. V4 stated R1 likes to transfer herself and it looked like that's what R1 was trying to do. V4 stated R1 did not remember what happened when asked. V4 stated V4 did an assessment on R1 and took R1's vital signs. V4 stated she gave R1's vital signs to V7 on a piece of paper but was unsure if V7 actually got the vital signs. V4 stated she did not document any assessment, vital signs, or any information about R1's fall and did not contact R1's family, V1 Administrator or V2 Director of Nurses. V4 stated V4 knows she is supposed to call the family and tell V1 Administrator. V4 stated V4 thought V7 was doing to do all that. V4 stated V7 did not go down to the room where R1 was found.The facility's Accidents and Incidents (WLC) - Investigation and Reporting policy dated Revised July 2017, directs staff to document the date and time resident's family member is notified of an accident. 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 Page 1 of 4 Event ID: 145945 Printed: 05/15/2026 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 145945 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 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)