Randolph County Care Center: Fall Safety Failures - IL
The resident, identified in inspection records only as R2, had already been documented as high risk for falls. Her care plan required non-skid socks or shoes whenever she was up in her wheelchair. She was moderately to severely cognitively impaired and needed substantial to maximal assistance just to transfer. Her balance was poor. She was incontinent. She was, by her own facility's assessment, unaware of her own safety needs.
None of that stopped her from hitting the floor on October 20.
A nursing assistant found her lying on her left side against the wall in front of her wheelchair. The incident report described what the nurse found: a hematoma at the center of her forehead, a second hematoma on the left side of her forehead, scant bleeding from her left cheek, a small scrape. Her glasses were broken. Her blood pressure was elevated. The on-call doctor ordered her sent to the emergency room to rule out a brain bleed.
When inspectors returned to Randolph County Care Center on October 23, they saw R2 in the dining room. She had bilateral black eyes. She was wearing plain white socks with no non-skid material on the soles.
The Director of Nursing told inspectors on October 27 that she expected fall interventions to be in place per the care plan, and that R2 was supposed to have non-skid socks or shoes on at all times when she was up in her wheelchair. She said she had not been aware the intervention was missing on October 23.
R2 was not the only resident whose fall protections had lapsed. A second resident, R1, had not had a floor mat placed near her bed and had not been placed on 15-minute checks, both of which her care plan required. A staff member explained the gap plainly: "We get report information from the nurse, we don't have time to go through the care plans."
That sentence does a lot of work. It describes, in one clause, the mechanism by which a fall prevention system fails. The care plan exists. The interventions are written down. The staff simply does not consult them during shift handoff, because there isn't time.
The facility's own fall policy, last reviewed in June 2023, lays out what is supposed to happen after a resident falls: assess for injury, notify the responsible party, investigate to determine whether the fall was avoidable or unavoidable, monitor vital signs, adjust the care plan as needed, and review updated interventions with the resident and their power of attorney. It also states that all residents are to be assessed for fall risk upon admission, with reassessments after every fall.
What the policy does not account for is a shift handoff where nurses summarize residents verbally and no one opens the care plan.
Federal inspectors cited the deficiency under F0689, which covers the obligation to protect residents from accidents. The level of harm was classified as minimal harm or potential for actual harm, affecting few residents.
R2 sat in the dining room three days after her emergency room visit, her eyes still black, her socks still smooth on the bottom.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Randolph County Care Center from 2025-11-19 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 20, 2026 · Our methodology
Randolph County Care Center in SPARTA, IL was cited for violations during a health inspection on November 19, 2025.
The resident, identified in inspection records only as R2, had already been documented as high risk for falls.
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.