The resident, who has Parkinson's disease and a history of cerebral infarction, told inspectors about the August incident: "I sure do. I broke my nose I thought it would never stop bleeding. After that I had two big black eyes. I fell flat on my face. It hurt a lot, and I was pretty anxious."
Her medical records show she suffers from osteoporosis, anxiety disorder, left hemiparesis, major depression, and delusional disorder. Despite these conditions, her cognitive abilities remain intact according to facility assessments. A fall risk evaluation classified her as high risk.
The accident occurred after lunch when a dietary aide wheeled the resident back to her room. "Neither of the footrests were in place," the aide told inspectors on October 14. "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."
A CT scan performed at 12:07 PM on August 16 confirmed bilateral nasal bone fractures and soft tissue hematoma overlying the inferior aspect of the frontal bone.
The resident explained how the missing footrests caused her fall: "My weak foot (Left) got caught on the front wheel and I went out of the chair on my face." She said staff had inconsistently used her footrests before the accident. "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."
A physical therapy assistant discovered the footrests stored in the resident's closet. "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."
Only after the resident returned from hospital treatment did therapy staff ensure both footrests remained properly attached. "Therapy put on both foot pedals when I got back from the hospital," the resident said.
The facility's Acting Director of Nursing confirmed that staff should have secured the footrests before transport. "It would be her expectation when staff is transporting a resident in a wheelchair the foot pedals should be in place," inspectors noted.
Yet the nursing home provided no written policy governing footrest use during wheelchair transfers.
Federal inspectors determined the facility failed to maintain an accident-free environment and provide adequate supervision. The violation resulted in actual harm to the resident, who endured weeks of pain, bleeding, and facial bruising from injuries that required hospitalization and CT imaging.
The resident's complex medical history made the fall particularly dangerous. Her osteoporosis increased fracture risk, while her stroke-related paralysis left her unable to protect herself during the fall. Her anxiety disorder likely worsened her distress during the bleeding and recovery period.
The dietary aide's account reveals how quickly the accident unfolded. After finishing lunch service, the aide transported the resident in the wheelchair without checking for proper footrest placement. The resident's weakened left leg immediately caught the front wheel, causing her to pitch forward onto the floor.
Staff response focused on addressing immediate bleeding rather than investigating how safety equipment went missing. The physical therapy assistant's discovery of footrests in the closet suggests they had been removed and stored rather than simply forgotten during transfer.
The resident's recovery extended well beyond the initial bleeding. "I had two big black eyes" that lasted for an extended period, she recalled. The bilateral nasal fractures and facial hematoma required ongoing medical monitoring and likely caused significant discomfort during healing.
Federal regulations require nursing homes to maintain environments free from accident hazards and provide supervision preventing resident injuries. The inspection found Mt Zion Health & Rehab Center failed both requirements when staff transported a high-fall-risk resident without essential wheelchair safety equipment.
The resident now sits in her wheelchair with both footrests properly secured, a precaution that came too late to prevent her face-first fall onto the nursing home floor.
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.
Additional Resources
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