Mt Zion Health & Rehab: Fall Safety Failures - IL
The same resident had no non-skid socks the next morning. Or the morning after that.
The resident, identified in inspection records only as R2, had been living at the facility on Woodland Drive since at least mid-2025. Her medical record lists more than a dozen diagnoses, among them Alzheimer's disease, left-sided hemiplegia, subdural hemorrhage, metabolic encephalopathy, and depression. She transfers by mechanical lift. Her fall care plan, initiated July 4, 2025, flagged her as at risk because of her medications, her Alzheimer's diagnosis, her depression, and her history of falls. One of the plan's interventions was specific and simple: non-skid socks, always.
On March 31, 2026, at 6:55 in the morning, R2 fell out of bed. Nobody saw it happen. She fractured her left orbital bone and her left maxilla, the bone that forms the upper jaw and the floor of the eye socket. She was taken to a hospital, where she received sutures near her left eye. Bruising spread across her face. She was admitted for hyponatremia, a dangerous drop in sodium levels.
She came back to Mt Zion Health & Rehab. Her fall risk assessment after the incident rated her at high risk for falls. The care plan remained in place.
Two months later, on May 26, inspectors watched two certified nursing assistants use a mechanical lift to move R2 from her bed to her wheelchair. She was not wearing non-skid socks. That same morning, at 10:20, R2 told inspectors she had recently fallen out of bed while sleeping.
At 11:00 that morning, one of the CNAs who had transferred R2 explained why she hadn't put the socks on. R2 doesn't stand, the aide said. So she didn't think it was necessary.
The following morning, May 27, at 10:00 AM, R2 still had no non-skid socks on. The morning after that, May 28, same thing.
Three consecutive days. The same resident. The same missing intervention. The same care plan sitting in her record.
The facility's own fall policy, dated September 2023, says that when a resident falls despite existing interventions, staff are supposed to add different ones, drop the ones that aren't working, or at minimum document why the current approach still makes sense. There is no indication in the inspection record that anyone reviewed R2's care plan after her March fall and decided the non-skid sock intervention was no longer relevant. The aide who skipped the socks didn't cite a clinical decision. She said R2 doesn't stand.
The logic has a flaw. Non-skid socks are not only for walking. A resident who transfers by mechanical lift, who has hemiplegia on one side, who has already fractured her face in an unwitnessed fall, is not a resident for whom sock friction is irrelevant. The care plan did not say "non-skid socks when standing." It said always.
Federal inspectors cited the facility for failing to implement a fall care plan intervention, a deficiency affecting a small number of residents. The level of harm was recorded as minimal harm or potential for actual harm, the lower end of the federal scale.
R2 had already learned, at 6:55 on a March morning, what potential for actual harm looks like. She woke up on the floor with her face broken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt Zion Health & Rehab Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
MT ZION HEALTH & REHAB CENTER in MOUNT ZION, IL was cited for violations during a health inspection on May 28, 2026.
The same resident had no non-skid socks the next morning.
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.