Mt Zion Health & Rehab Center
MT ZION HEALTH & REHAB CENTER in MOUNT ZION, IL — inspection on April 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
next to her bed with her head at the head of her bed.
Bed was in low position, socks and house
sitting on the side of bed attempting to go to the bathroom and fell out of bed.
This report documented
she witnessed R5's fall on the day R5 was sent to the hospital with an injury. R6 stated R5 was sitting on the side of the bed, which R6 described as approximately knee height (about 2 feet off the ground), when R5 slipped off the side of the bed and fell.R6 stated that no fall mats were in place at the time of the fall and pointed to fall mats that were observed on the bed during this interview. R6 stated those mats were placed on the floor after R5 fell. R6 further stated that R5 had a history of frequent falls out of bed.On 4/27/2026 at 12:25 p.m., V9, Licensed Practical Nurse (LPN), stated she was the nurse caring for R5 on 3/25/2026 when R5 fell. V9 stated V3, Social Services Director (SSD), informed her that R5 was found lying on her back on the floor beside the bed, with the head positioned toward the head of the bed and feet toward the foot of the bed. V9 stated upon entering R5's room she found R5 on the floor and the bed was approximately knee height and that no fall mats were in place at the time of the fall.V9 stated that a CNA had taken R5 to the bathroom prior to the incident and that she was unsure why fall mats were not placed on the floor, noting that the Kardex indicated mats were to be in place. V9 stated that R5 was a known fall risk with a history of previous falls and that a call, don't fall sign was in place. V9 stated R5 was unable to explain how the fall occurred and was observed grabbing the right buttock and stating, ouch, ouch, please help me.On 4/27/2026 at 12:55 p.m., V3, Social Services Director (SSD), stated that R6 (R5's roommate) alerted staff that R5 had fallen and was on the floor complaining of hip pain. V3 stated she found R5 lying on her right side in a fetal position next to her bed, which was approximately at knee height.On 4/27/2026 at 1:22 p.m., V15, Licensed Practical Nurse (LPN), stated she responded to R5's room after hearing commotion in the hallway. V15 reported that she observed R5 lying on her right side on the floor next to the bed, with her back facing the bed, and complaining of right hip pain. V15 stated the bed was approximately knee height (about 3 feet off the floor) and confirmed that no floor mats were in place at the time of the fall.On 4/27/2026 at 2:02 p.m., V14, Certified Nurse Assistant (CNA), stated she had been in R5's room approximately 20 minutes prior to the fall and that a newly hired CNA, V16, whom she was training, was the last staff member to see R5 prior to the incident. V14 reported that shortly thereafter, she was alerted that R5 was on the floor and, upon entering the room, observed R5 lying on her right side. V14 stated that R5 reported she attempted to get up to close her door and fell while trying to stand. V14 confirmed that R5 was a known fall risk but was unsure whether required fall interventions, including fall mats, were in place at the time of the fall.On 4/27/2026 at 2:36 p.m., V16, CNA in training, stated she recalled a fall that occurred on her first day of training on 3/25/2026. V16 reported that she entered R5's room to assist the roommate (R6) and observed R5 sitting on the edge of the bed. V16 stated that R5 did not request assistance, and she was unsure why R5 was sitting on the side of the bed.V16 stated that approximately ten to fifteen minutes later, she and her trainer (V14) were informed that R5 was found on the floor next to the bed. V16 stated there was not a fall mat in place at that time.On 4/28/2026 at 11:05 a.m., V2, Director of Nursing (DON) stated V16, CNA should have responded to R5 sitting on the side of the bed and should have recognized that appropriate fall interventions were not in place. V2 further stated that V14, CNA should have remained with V16, as it was her first day of training and she was not yet familiar with the residents.X-ray results in R5's EHR, dated 03/25/26, document an acute, mildly displaced fracture of the right greater trochanter following the fall.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.