Countryside Care Center: Trip Hazard Fall Causes Injury - IL
On August 5, 2025, a resident identified in inspection records as R1 tripped over a worn, nine-foot-long nonskid mat positioned in front of the facility's entry door. She hit her head on the staff breakroom door. When the ombudsman visited on August 28, she found R1's face bruised under both eyes and across her nose.
R1 told the ombudsman she had tripped over the rug.
The mat had been a known problem before that Tuesday. The weekend before the fall, residents had complained to a registered nurse that the rug was in disrepair and needed to be replaced. That nurse passed the complaints to the administrator. A new mat was ordered on August 4, the day before R1 fell. The worn mat stayed on the floor.
The administrator told inspectors on August 29 that staff had tried taping down the corner of the mat to keep it flat. It lasted a couple of days, then it rolled back up again.
The ombudsman also spoke with R2, the Resident Council President, who told her that management had been made aware of the rug being a trip hazard before R1 fell. That detail placed the knowledge higher than a single nursing conversation. Management knew. The mat remained.
The maintenance worker who ultimately threw the mat away described it without hesitation. "I carried it to the dumpster the same day that she fell," he told inspectors. The mat was gone by the end of August 5. The decision that could have been made days earlier, or the weekend before, or whenever the first resident complained, was made only after R1's face was bruised in two places.
Federal inspectors, who completed their review on September 3, 2025, cited the facility under F0689, the tag covering accident hazards and supervision. The level of harm was listed as actual harm. The number of residents affected was listed as few.
What the inspection record captures is a sequence that moved in one direction from the start. Residents complained. A nurse heard them and told the administrator. Staff discussed pulling the mat. Someone taped the corner down. The tape didn't hold. A new mat was ordered. The old one stayed. A resident tripped, hit her head, and walked around for more than three weeks with bruising across her nose and under both eyes before an outside visitor noticed.
The ombudsman's visit on August 28 was what prompted the documented account. By then R1 had been living with the injury for 23 days.
The maintenance worker's words are the detail that stays. Not a policy gap, not a documentation failure, not a staffing ratio. Just a group of people who saw what was coming and said so out loud, and then waited. "Someone is going to trip over it." The mat sat there. R1 tripped over it. He carried it to the dumpster.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Care Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
COUNTRYSIDE CARE CENTER in MACOMB, IL was cited for violations during a health inspection on September 3, 2025.
She hit her head on the staff breakroom door.
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.