Landmark of Cicero: Fall Care Plan Failures After Fracture - IL
The resident, identified in inspection records only as R1, had been living at the facility since at least March 2025. Her care plan from that month noted she was not at risk for falls. The only intervention the plan listed: nursing staff would complete a fall risk assessment per facility protocol. That single line sat unchanged through reviews in June and again in September, right up until the day she ended up on the floor.
A nurse found her lying on her stomach near a table. R1 told staff she had moved away from another resident who was reaching for her, grabbed that resident's coffee, and it spilled. The fall report catalogued what the care plan had never accounted for: impaired memory, impulsive behavior, agitation, delusions, hallucinations, decreased safety awareness, and the use of high-risk medications including antipsychotics.
Two days later, she was in the emergency room.
CT scans told the rest. Her right shoulder showed an acute traumatic comminuted fracture through the lateral greater tuberosity, a transverse fracture through the surgical neck, five millimeters of impacted foreshortening across that fracture line, and a separate fracture along the bicipital groove. Soft tissue swelling surrounded the shoulder. Fluid had collected in the joint. A second scan of her facial bones found a displaced fracture of the left nasal bone.
An occupational therapist evaluated her on September 24. The findings were direct: R1 had declined in strength, balance, and activity tolerance. Her right arm was non-weight bearing. She needed maximum staff assistance with daily activities. The therapist concluded she was at risk for falls.
The director of nursing completed her fall risk review on September 23, the day R1 returned to the facility from the hospital. On the form, where it asked whether R1 had a history of falls within the last three months, the director checked no. Where it asked whether R1 had any health conditions predisposing her to fall risk, the answer recorded was none.
When inspectors asked about this on October 20, the director of nursing said she had interpreted the fall history question to mean falls other than the one that had just happened. Then she said something more direct: R1 is not at risk for falls.
The administrator offered a different account a week later, on October 27. Any resident who comes into the facility, the administrator said, is always at risk for falls. When someone falls, they are put on high risk no matter how many times it has happened. They receive a yellow wristband. Their care plan is updated to reflect fall risk.
The inspection record contains no indication that any of this happened for R1 after her September 19 fall. There is no high-risk care plan. There is no documentation of a yellow wristband. The care plan initiated in March, the one that said she was not at risk, was never replaced with one that acknowledged she had fallen, fractured her shoulder in three places, broken her nose, and come back from the hospital unable to use her right arm.
The facility's own fall prevention policy, dated August 2017, states that when a fall occurs, additional interventions will be implemented to prevent another one. The care plan policy, undated, says care plans will be reviewed and updated with any significant change in condition.
A broken shoulder and a fractured nose did not produce a single new intervention on paper.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, the lowest tier on the federal scale. The finding covered one resident out of three reviewed.
R1's occupational therapy notes from September 24 describe a woman who could not bear weight on her right arm, who needed maximum help getting through her day, and who the therapist assessed as a fall risk. Those notes were in the chart. The fall risk review completed the day before, by the director of nursing, reached the opposite conclusion and left the fall history blank.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark of Cicero Rehabilitation and Nursing Cent from 2025-10-28 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 6, 2026 · Our methodology
Landmark of Cicero Rehabilitation and Nursing Cent in CICERO, IL was cited for violations during a health inspection on October 28, 2025.
The resident, identified in inspection records only as R1, had been living at the facility since at least March 2025.
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.