Apostolic Christian Restmor: Fall Alarm Failure - IL
Federal inspectors cited the facility following a complaint inspection completed September 3, 2025, finding that the breakdown caused actual harm to the resident, identified in inspection records as R1.
The alarm had one job. For residents deemed high-risk for falls, the facility placed silent bed alarms on their beds, devices that alert staff the moment a resident begins to rise so someone can get there before a fall happens. The Director of Nursing confirmed that any resident flagged as high-risk, anyone who had already fallen out of bed or tried to transfer on their own, was supposed to have one of these alarms, and it was supposed to go on the care plan as a documented intervention.
When R1 got up, the alarm did not go off. Staff were not alerted. Nobody came. R1 fell.
A nurse who responded afterward told inspectors her focus immediately shifted to R1's condition. "I remember calling [R1's Primary Physician] and letting them know what was going on and then getting [R1] sent out to the hospital," she said. "That was my focus because [R1] seemed injured."
The facility's own investigation, conducted by a registered nurse, concluded that the silent bed alarm had not been functioning properly at the time R1 got up. That malfunction was identified as the root cause of the fall.
The fix the facility put in place was to swap out the broken alarm for a new one.
That was it, at first. There was no new protocol to check whether alarms were working before residents were placed on them. No system to catch the next malfunctioning device before another resident hit the floor.
The Director of Nursing, speaking with inspectors on September 2, 2025, acknowledged as much. "The care plan intervention for [R1's] fall on 10/18/23 was to replace the malfunctioning bed alarm with a new alarm, so I am assuming the bed alarm was not functioning properly as it should," she said. Then she added: "We put in place around a year for staff to check the bed alarms each shift to ensure proper functioning, which include staff tapping on the bed alarm first to ensure the bed alarm beeps and is functioning properly prior to placing resident on the bed alarm."
R1 fell on October 18, 2023. The new shift-check procedure came roughly a year later.
That gap is the center of what inspectors found. The facility knew the alarm had failed. It knew the alarm was the reason nobody reached R1 in time. It replaced the broken device and updated the care plan. But for approximately a year, staff had no standard process for verifying that any bed alarm, on any resident, was actually working before that resident was left to depend on it.
A staff member confirmed to inspectors that the facility does rely on silent bed alarms for high-risk residents as part of its fall prevention approach. The alarms are not a backup measure. For residents who cannot safely get out of bed on their own, they are the primary early warning system between a resident deciding to move and a staff member being close enough to help.
When that system fails silently, it fails completely. There is no sound, no alert, no second layer. The resident moves. Nobody knows.
The inspection deficiency was cited under F0689, the federal tag covering the requirement that facilities protect residents from accident hazards, and it was tagged at a level of actual harm, meaning inspectors determined R1 suffered real injury as a result of the failure, not merely that harm was possible.
The facility serves a relatively small number of residents affected by this finding, according to the inspection record, which notes "few" residents were involved.
R1 was taken to the hospital. The inspection report does not describe the extent of the injuries beyond the nurse's statement that R1 seemed injured at the time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Apostolic Christian Restmor from 2025-09-03 including all violations, facility responses, and corrective action plans.
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 25, 2026 · Our methodology
APOSTOLIC CHRISTIAN RESTMOR in MORTON, IL was cited for violations during a health inspection on September 3, 2025.
When R1 got up, the alarm did not go off.
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.