F0689

D

Failure to Implement Care-Planned Floor Mattress for Resident With Fall History

Lake Forest, Illinois Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that fall-prevention interventions were in place for a resident with a known history of falls. The resident’s face sheet dated 1/26/26 documented a diagnosis that included a history of falling, and the fall care plan initiated on 7/7/24 indicated the resident had fallen at the facility and had a history of falling out of bed. The care plan listed use of a floor mattress as an intervention. However, on 1/26/26 at 10:14 AM, the resident was observed in bed with no floor mattress on the floor next to the bed; instead, the mattress was propped up against the wall near the head of the bed, and no staff, family, or caregivers were present in the room. On 1/27/26 at 12:07 PM, a CNA stated that floor mattresses should be placed on the floor next to the bed when the resident is in bed.

This deficiency reflects that the facility did not implement the care-planned intervention of a floor mattress for a resident with a documented history of falls and falling out of bed, despite staff acknowledging that the mattress should be in place when the resident is in bed.