Imboden Creek Senior Living

In the surveyor’s words

From the most serious findings on record at Imboden Creek Senior Living, in the surveyor’s own words.

• Immediate jeopardy, patternF678May 18, 2023

  Based on interview and record review, the facility failed to provide and properly maintain essential lifesaving medical equipment during a respiratory medical emergency for R1. R1 did not receive effective rescue breathing for 12 minutes during CPR (Cardiopulmonary Resuscitation) due to the absence and/or availability of a mechanical ventilation device or mouth shield for staff use during a respiratory medical crisis. R1 subsequently died of Acute Cardiopulmonary Arrest. These failures have the potential to affect (13) additional residents (R4 - R11 and R15 -R19) who have chosen to be a Full Code. […]

• Immediate jeopardy, isolatedF678Nov 6, 2025

  Based on interview and record review, the facility failed to provide emergency response resuscitative efforts timely, resulting in a ten-minute delay in life saving services for one (R1) resident out of six residents reviewed for Death in a sample list of eleven residents. On [DATE], R1 was confirmed to be without signs of life ten minutes prior to the initiation of Cardiopulmonary Resuscitation (CPR). R1 subsequently expired at the facility on [DATE] at 9:45 am.Findings include:The Immediate Jeopardy began on [DATE] when facility staff noted R1 to be without signs of life and did not initiate CPR (Cardiopulmonary Resuscitation). V1, Administrator,was notified of the Immediate Jeopardy on [DATE]/25 at 4:27 PM. […]

• Actual harm, isolatedF689Aug 27, 2026

  Based on observation, interview, and record review, the facility failed to implement fall interventions for four of five residents (R3, R1, R4, R5) reviewed for falls in the sample list of five. This failure resulted in R3 sustaining a laceration and requiring sutures. Findings include:1.) R3's Minimum Data Set (MDS) ,dated 7/31/26,documents R3 is cognitively intact.R3's Care Plan, dated 7/1/26, documents R3 is at risk for falls, with interventions including R3's call light needs to be within reach and R3 needs assist with ambulation, transfers, and locomotion on and off the unit. R3's Care Plan, dated 8/12/2026, documents a call don't fall sign is to be placed in R3's room as a reminder to call for help. On 8/25/2026 at 9:35 AM, there was no call don't fall sign in R3's room. […]

• Actual harm, isolatedF600Jul 2, 2026

  Based on interview and record review, the facility failed to ensure residents were free from verbal abuse from facility staff members for one (R2) of five residents reviewed for abuse in the total sample list of six. This failure resulted in R2 being made to feel pressured, outnumbered, and extremely insignificant. Findings include:R2's Minimum Data Set (MDS), dated [DATE], documents R2 has diagnoses including Frontal Lobe and Executive Function Deficit Stroke, Atrial Fibrillation, Cerebrovascular accident (CVA), and Hemiparesis. […]

• Actual harm, isolatedF689Jan 13, 2026

  Based on observation, interview, and record review, the facility failed to provide effective resident supervision to prevent repeat traumatic falls. These failures resulted in R7 experiencing 14 or more falls between November and December 2025 causing abrasions, skin tears, a hematoma, swelling, pain, and an eyebrow laceration requiring emergency transfer to the hospital for surgical repair. R7 is one of two residents reviewed for accidents on the sample list of 29.Findings include:R7's diagnosis list (1/7/2026) documents diagnoses including Metabolic Encephalopathy (brain dysfunction caused by metabolic imbalance), Convulsions, Muscle Wasting and Atrophy, Lack of Coordination, Unsteadiness on Feet, History of Falling, Neurocognitive Disorder, Dementia, Repeat Falls, Major Depressive… […]