The resident fell at Mt Zion Health & Rehab Center on August 16 when her paralyzed left foot got caught in the wheelchair's front wheel. She landed on her face with a bleeding nose and forehead hematoma severe enough to require emergency transport to the hospital, where a CT scan revealed bilateral nasal bone fractures.
Federal inspectors found the facility failed to maintain accurate medical records about the fall, with staff accounts directly contradicting each other and the official incident report.
"I broke my nose I thought it would never stop bleeding," the resident told inspectors in October. "After that I had two big black eyes. I fell flat on my face. It hurt a lot, and I was pretty anxious."
The resident, who has Parkinson's disease and a history of stroke, explained what happened: "Before I fell, sometimes they would put on one of my foot pedals. When I fell, I didn't have on either one of the pedals. My weak foot got caught on the front wheel and I went out of the chair on my face."
A dietary aide who witnessed the fall corroborated this account. "Neither of the footrests were in place," the aide told inspectors. "Her bad leg got caught in the front wheel of the wheelchair and she went to the floor on her face. Her nose was bleeding bad, so I got the nurse right away. I was the only one who saw the fall happen."
The physical therapy assistant who evaluated the resident after the accident also confirmed the footrests were missing. "I think when she fell her footrests were in her closet," the assistant said. "We assessed her after the fall and put the footrests in place."
But the facility's official incident report told a different story entirely.
The licensed practical nurse who responded to the emergency wrote that "resident was being wheeled from the dining room back to her room at 0852am when her foot fell off her footrest and got caught under the chair causing resident to fall out the chair." This suggested the footrest was present but the resident's foot had slipped off it.
More significantly, the facility's final incident report to state regulators claimed the resident's "foot pedals were in place at the time of the fall" — directly contradicting what the resident, the eyewitness, and the therapy staff all reported.
The nurse who wrote the initial progress note was not even listed as a witness on the facility's incident report, despite being the first medical professional to respond and document the injuries.
The resident required emergency medical transport within minutes of the fall. Fire department personnel arrived at 9:05 a.m., followed by EMS crews who found her alert and oriented. She was able to clearly describe the accident to paramedics: "My left foot slipped off my footrest and got caught under my chair caused me to flip over."
Hospital records show she suffered bilateral nasal bone fractures and soft tissue hematoma on her forehead from the impact.
The resident was considered high-risk for falls and had multiple conditions that increased her vulnerability, including left-side weakness from her previous stroke, Parkinson's disease, diabetes, and a history of shoulder replacement surgery. Her care plan documented anxiety disorder and major depression alongside her physical limitations.
When inspectors confronted the facility administrator about the contradictory documentation in October, he acknowledged the problems. "I am aware of discrepancies in documentation and other issues with V11 and that is why we terminated V11," the administrator said, referring to the former director of nursing who signed the final incident report.
The resident told inspectors that therapy staff only ensured both footrests were properly installed after she returned from the hospital with her broken nose.
Federal inspectors cited the facility for failing to maintain accurate medical records, finding that the contradictory accounts represented a failure to follow accepted professional standards for documentation. The violation affected the resident's safety by creating an inaccurate record of the circumstances that led to her serious injuries.
The discrepancies raise questions about whether the facility properly investigated the fall or took adequate steps to prevent similar accidents for other residents with mobility limitations and fall risks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt Zion Health & Rehab Center from 2025-10-14 including all violations, facility responses, and corrective action plans.
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