Inspection·October 14, 2025

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 (R1) reviewed for accidents in a sample list of three residents. This failure resulted in R1 sustaining a nasal bone fracture when R1 fell out of the wheelchair on to R1's face.Findings Include: 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. R1's Fall Risk assessment dated [DATE] documents R1 is at high risk for falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact.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 R1 was seated in her room in her wheelchair. Both foot pedals were in place on R1's wheelchair. When asked if R1 recalled falling out of her wheelchair about a month ago 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 (R1) fell and broke her nose we had just finished the meal, and I took (R1) in her wheelchair to her room. Neither of the footrests were in place. (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 (R1) fell her footrests were in her closet. We assessed (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 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 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)