Mt Zion Health & Rehab Center

F 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to safely transport a resident in a wheelchair for one of three residents (Resident R1) reviewed for accidents in a sample list of three residents. This failure resulted in Resident R1 sustaining a nasal bone fracture when Resident R1 fell out of the wheelchair on to Resident R1's face.Findings Include: Resident R1's Care Plan updated 10/10/25 includes the following diagnoses: Osteoporosis, Anxiety Disorder, Left Hemiparesis, Major Depression, Delusional Disorder, History of Right Shoulder Replacement, Parkinson's Disease, Type II Diabetes, and History of Cerebral Infarction. Resident R1's Fall Risk assessment dated [DATE REDACTED] documents Resident R1 is at high risk for falls. Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 is cognitively intact.Resident R1's CAT (Computerized Axial Tomography) scan dated 8/16/25 at 12:07PM documents Bilateral Nasal Bone Fracture. Soft Tissue Hematoma noted overlying the inferior aspect of the frontal bone.On 10/14/24 at 1:30PM Resident R1 was seated in her room in her wheelchair. Both foot pedals were in place

on Resident R1's wheelchair. When asked if Resident R1 recalled falling out of her wheelchair about a month ago Resident R1 stated 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. I had a stroke, and I am partly paralyzed on my left leg.

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 (Left) got caught on the front wheel and I went out of the chair on my face.

Therapy (staff) put on both foot pedals when I got back from the hospital.On 10/14/25 at 1:40PM V8 Dietary Aide stated When (Resident R1) fell and broke her nose we had just finished the meal, and I took (Resident R1) in her wheelchair to her room. Neither of the footrests were in place. (Resident R1's) 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.On 10/14/25 at 1:56PM V7, Physical Therapy Assistant stated I think when (Resident R1) fell her footrests were

in her closet. We assessed (Resident R1) after the fall and put the footrests in place.On 10/14/25 at 2:10PM V7, Acting Director of Nursing verified it would be her expectation when staff is transporting a resident in a wheelchair the foot pedals should be in place. The facility did not provide a policy for use of foot pedals

during transfer.

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

MT Zion Health & Rehab Center

1225 Woodland Drive Mount Zion, IL 62549

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to maintain an accurate medical record for one resident (Resident R1) of three residents reviewed for medical records in a sample list of three residents.Findings include:Resident R1's Care Plan updated 10/10/25 includes the following diagnoses: Osteoporosis, Anxiety Disorder, Left Hemiparesis, Major Depression, Delusional Disorder, History of Right Shoulder Replacement, Parkinson's Disease, Type II Diabetes, and History of Cerebral Infarction. Resident R1's Fall Risk assessment dated [DATE REDACTED] documents Resident R1 is at high risk for falls. Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 is cognitively intact.Resident R1's CAT (Computerized Axial Tomography) scan dated 8/16/25 at 12:07PM documents Bilateral Nasal Bone Fracture. Soft Tissue Hematoma noted overlying the inferior aspect of the frontal bone.On 10/14/24 at 1:30PM Resident R1 was seated in her room in her wheelchair. Both foot pedals were in place.

When asked if Resident R1 recalled falling out of her wheelchair about a month ago Resident R1 stated 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. I had a stroke, and I am partly paralyzed on my left leg. 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 (Left) got caught on the front wheel and I went out of the chair on my face. Therapy (staff) put

on both foot pedals when I got back from the hospital.On 10/14/25 at 1:40PM V8 Dietary Aide stated When (Resident R1) fell and broke her nose we had just finished the meal, and I took (Resident R1) in her wheelchair to her room.

Neither of the footrests were in place. (Resident R1's) 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.On 10/14/25 at 1:56PM V7, Physical Therapy Assistant stated I think when (Resident R1) fell her footrests were in her closet. We assessed (Resident R1) after the fall and put the footrests in place.Resident R1's progress note dated 8/16/25 at 2:36PM by V13, LPN (Licensed Practical Nurse) documents 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. Resident fell face first to the floor, Resident was observed lying face down with her arms under her. Residents nose was bleeding a significant amount of blood, and a hematoma was noted to the resident's forehead. 911 was called at 0854, POA (Power of Attorney) was notified of fall at 0904am who then gave instructions to send (Resident R1 to local hospital). Fire department arrived at 0905 and (local) EMS (Emergency Medical Services) arrived shortly after, Resident was able to give a clear description of what happened to EMS, My left foot slipped off my footrest and got caught under my chair caused me to flip over. On Call nurse notified of incident at 0912, DON (Director of Nursing) notified at 0914am. Writer then spoke with (Medical Doctor) at 0914 am. Report given to (local hospital) (charge nurse) at 0917. When leaving facility resident was A&O x3 (alert and oriented times three), Pupils and hand grips were equal. V13 is not listed on the facility Incident report as having witnessed the fall. The facility's final incident report to the state agency by V11, former DON dated 8/22/25 documents Resident R1's foot pedals were in place at the time of the fall.On 10/14/25 at 2:30PM when asked about

the discrepancies in the documentation of the 8/16/25 fall for Resident R1, V1, Administrator stated I am aware of discrepancies in documentation and other issues with V11 and that is why we terminated V11.

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