Landmark Of Cicero Rehabilitation And Nursing Cent
Landmark of Cicero Rehabilitation and Nursing Cent in CICERO, IL — inspection on October 28, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed, and revised by a team of health professionals.
new interventions to prevent or reduce the risk of further falls.
This affected one of three residents
at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: bipolar disorder with mood and/or behavioral disturbance.
The only intervention noted: nursing staff will complete a fall risk assessment per facility fall protocol.
This intervention was reviewed on 3/18, 6/23, and 9/22.There is not an at risk for falls care plan initiated prior to R1's fall or a high risk for falls due to actual fall care plan initiated post fall on 9/19/25.R1's falls report, dated 9/19/25, notes V4 (nurse) observed R1 on floor lying near table on stomach. R1 stated R1 moved away, another resident was going to touch R1, R1 took the other resident's coffee, and it spilled.
Predisposing physiological factors include impaired memory, impulsive, agitated/anxious, delusions, use of high-risk medications, decreased safety awareness, receives antipsychotics, and hallucinations.R1's hospital record, dated 9/21/25, notes R1 presented to the emergency room after a traumatic fall. R1's CT (computed tomography) scan of right shoulder shows an acute traumatic comminuted fracture through the lateral greater tuberosity and transverse surgical neck fracture.
There is 5mm (millimeters) impacted foreshortening across the surgical neck fracture. A fracture line is noted along the deep lateral portion of the bicipital groove.
Generalized soft tissue swelling around the shoulder and posttraumatic joint effusion. CT scan of R1's facial bones show a mildly displaced left nasal bone fracture.R1's fall risk review, dated 9/23/25, notes fall history - does R1 have a history of falls within the last three months; response documented is no.
Health conditions - does resident have any health condition that predisposes them to be at risk for falls (other fractures); response documented is none.R1's occupational therapy evaluation, dated 9/24/25, notes R1 with a decline in strength, balance, activity tolerance, and non-weight bearing right arm. R1 requires maximum staff assistance with ADLs (activities of daily living).
Due to the documented physical impairments and associated functional deficits, R1 is at risk for falls.On 10/20/25 at 1:20 PM, V2, DON (Director of Nursing) stated a residents care plan should be reviewed and updated after each fall. V2 stated V2 completed R1's fall risk review when R1 was re-admitted after a fall on 9/23/25.
When questioned reason V2 noted ?no' on R1's fall history (does R1 have a history of falls within the last three months), V2 responded V2 interpreted this to mean falls other than the current fall on 9/19. V2 stated R1 is not at risk for falls.On 10/27/25, V1 (Administrator) presented the following: any resident who comes into the facility is always at risk [for falls].
When someone falls, they are put on high risk for falls no matter how many falls they have had.
They are given a yellow wrist band.
Care plans are at risk for falls.
The facility's care plan policy, undated, notes residents' care plans will be reviewed and updated with any significant changes in condition.The facility's fall prevention and management program policy, dated 8/3/2017, notes the purpose is to ensure that in the event a fall occurs, additional interventions will be implemented to prevent another fall from occurring.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145850 10/28/2025
Landmark of Cicero Rehabilitation and Nursing Cent 5825 West Cermak Road Cicero, IL 60804
stated he does not recall any further details, but his note dated 9/20 is an accurate account of
returned call to R1's family member and updated family member on R1's condition. V7 assured R1's
medication to relieve the pain pending the outcome of the x-ray. V7 also explained to R1's family member R1 confirmed to V7 that R1 took and spilled peers coffee, who in turn swung back at R1, leading to a fall. On 10/22/25 at 2:00 PM, V8, CNA (Certified Nurse Aide) stated she worked 9/19 day shift and evening shift, but denied working on the eighth-floor nursing unit where R1 resided.
The facility's staffing assignment sheet, dated 9/19/25, notes V8 assigned to work on the eighth-floor nursing unit day shift and evening shift. It also notes V8 documented her initials next to her name.On 10/23/25 at 10:08 AM, V9, LPN (Licensed Practical Nurse) stated she worked a double shift from 9/20 at 11:00 PM until 9/21 at 3:00 PM and was assigned to provide care for R1. V9 stated R1 did complain of pain to right arm. V9 stated she received report that R1 fell and R1 had swelling to right arm as a result. R1 was receiving pain medication. V9 stated the x-ray results were known on 9/21 in the morning. V9 stated the x-ray showed fracture. R1 also had discoloration to his right eye. R1 exhibits periods of anxiety in which R1 paces on the nursing unit. R1 paces daily.
The facility's fall prevention and management program policy, dated 8/3/2017, notes the purpose is to ensure that in the event a fall occurs, additional interventions will be implemented to prevent another fall from occurring.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.