F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to assess a resident before transferring to a
wheelchair following a fall. This failure affects one (R3) of four residents reviewed for falls in the sample list
of four. This past non-compliance occurred from 5/27/24 to 5/28/24.
Residents Affected - Few
Findings include:
The facility's Accidents & Incidents policy with initiated date of July 01, 2023 documents in section 2.
Assisting Accident/Incident Victims: A. Render immediate assistance. DO NOT move the victim until he/she
has been examined for possible injuries. B. If assistance is needed, summon help. If you cannot leave the
victim, ask someone to report to the nurses station that help is needed, or if possible, use the call system
located in the resident's room to summon help.
R3's Minimum Data Set completed on 05/10/2024 documents a Brief Interview for Mental Status score of
14 indicating R3 is Cognitively Intact.
R3's Care Plan dated 4/30/24 states R3 is at risk for falls and injuries related to Metabolic Encephalopathy,
Hypertension, Coronary Artery Disease and Multiple Sclerosis.
R3's Progress Note dated 5/27/2024 at 06:05 AM by V3, Licensed Practical Nurse, documents a Certified
Nurses Aide (CNA) brought R3 to the nurses station in a wheelchair and stated the resident had fallen and
was found crawling on floor and the resident was complaining of right hip pain. The Progress Note
documents the resident was taken to her room and placed in bed and was unable to straighten her right leg
or bend her knee. The Note documents the resident stated the pain was 10 out of 10 on a one to 10 scale
and the resident was grimacing when the writer touched the right hip. The Note documents the Assistant
Director of Nurses, the resident's Power of Attorney, and the Physician were notified and the resident was
sent to the emergency room for evaluation.
R3's Fall Investigation dated 5/27/24 at 2:42 PM documents R3 sustained a fractured right hip and was
discharged to the hospital. The Fall Investigation documents a CNA saw R3 crawling on R3's hands and
knees. V5's (CNA) Investigation Statement documents R3 did not hurt and V5 asked V4, CNA to help V5
get R3 up. V4's Investigation Statement documents that V5 and V4 used a sheet in a sling type fashion and
transferred R3 to a wheelchair. V4's statement documents that R3's fall was not witnessed. The Fall
Investigation documents V4 stayed with the resident while the nurse was notified of the fall.
On 6/5/24 at 2:16 PM V3 stated V5 brought R3 to the nurses station in a wheelchair. V3 stated V5 told V3
that R3 had an unwitnessed fall and V5/V4 transferred R3 to the wheelchair using a bed sheet as a sling.
V3 stated R3 was complaining of right hip pain. V3 stated R3 was returned to the bed for
(continued on next page)
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
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145546
Printed: 05/15/2026
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
145546
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
assessment. V3 stated V5 and V4 transferred R3 from the floor to the wheelchair using a bed sheet as a
sling before V3 was notified of the fall and could assess R3 for injury.
On 6/6/24 at 11:37 AM, V1 Administrator and V2 Director of Nursing, agreed that R3's Progress Note dated
5/27/2024 at 06:05 AM states the resident was transferred from the floor to a wheelchair by nursing staff
without first being assessed by a nurse. V1 and V2 stated the resident should not have been transferred off
the floor, that a nurse should have been alerted to R3 being on the floor from an unwitnessed fall and a
nurse should have assessed R3 before transferring R3 to a wheelchair.
Prior to the survey date of 6/6/24, the facility took the following actions to correct the non compliance.
1. On 5/28/24 all staff were in-serviced on the fall policy. Specifically when a resident falls, the resident is
not to be moved for any reason until a nurse assesses the resident. An employee must stay with the
resident until the nurse arrives. At that point the nurse will decide if the resident is to be moved and how to
assist the resident.
2. On 5/28/24 an Ad Hoc QAPI (Quality Assurance Performance Improvement) plan was put into place.
Medical record audits were started. An audit tool dated 5/27/24 to 6/03/24 was provided. The audit tool
states the Director of Nursing or designee will monitor three residents for falls including: Care Plans,
assessments, pain review, interventions, and transfer assessments. This will be completed weekly for 4
weeks, with week one being completed at this time.
3. Chart Audits dated 5/27/24 were completed for fall risk, transfer status, care plan review, interventions
and pain assessments.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145546
If continuation sheet
Page 2 of 2
