Mt Zion Health & Rehab Center

Inspectors wroteBased on observation and interview, the facility failed to properly store medications in a locked medication cart that was accessible to the residents and visitors in the facility. This failure has the potential to affect all 68 residents residing in the facility on 7/31/2026. Findings Include:On 7/31/2026 at 10:36am, V1 Administrator provided a resident census documenting 68 residents residing in the facility on 7/31/2026. On 7/31/2026 at 10:07am, an unlocked medication cart was observed located in the facility library. The medication cart contained numerous loose unlabeled medications in the drawers. On 7/31/2026 at 12:39pm, R4 and V4 (R4's) Family Member were observed sitting in the facility library with the unlocked medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were documented as administered after the resident received medications for ten (R2, R4, R6-R8, R11, R13-R16) of 16 residents reviewed for medication administration on a sample list of 16. The Facility's Charting and Documentation Policy dated 7/1/24 documents medications administered should be documented the date and time the medication was provided. The Facility's Medication Administration Procedure Policy dated 11/7/19 documents to chart the medications administered after resident has swallowed medications. On 7/13/26 at 10:20AM, V4 Licensed Practical Nurse (LPN) was observed preparing and administering medications for R2. R2's electronic medical record (EMR) documents R2 received these medications at 8:15AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement a fall care plan intervention for one of three residents (R2) reviewed for accidents in the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to obtain a laboratory test for one (R2) of three residents reviewed for accidents in the sample of three.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure appropriate supervision for a resident identified as a high fall risk and failed to implement care-planned fall interventions for one of three (R5) residents reviewed for accidents from a sample of five. This failure resulted in R5 sustaining a fall that resulted in a displaced fracture in the upper portion of R5's right leg.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four.

Inspectors wroteDeficiencies at this level require more than one Deficient Practice Statement. A. Based on interview and record review the facility failed to implement a Legionella surveillance program. This failure has the potential to affect all residents who reside in the facility. B. Based on interview and record review the facility failed to appropriately sanitize a glucometer following use for one resident (R48) of one resident screened for blood glucose monitoring in a sample list of 38 residents. A. The facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS-671) dated 01/05/2026 documents that 64 residents reside in the facility. The facility policy titled Infection Prevention & Control: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two (R6,R45) of four residents reviewed for abuse in the sample list of 38.

Inspectors wroteBased on interview and record review, the facility failed to report to the state an allegation of resident-to-resident abuse for two (R61, R66) out of four residents reviewed for abuse, on a sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to a resident who was dependent on staff for assistance with (Activities of Daily Living (ADLs) for one resident (R54) of two reviewed for ADLs on a sample list of 38.

Inspectors wroteBased on interview and record review the facility failed to coordinate hospice care with hospice provider for one resident (R70) of two residents reviewed for hospice in a sample list of 38. Findings Include: R75's care plan, updated on 12/27/2025, includes the following diagnoses: chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome. R75's Minimum Data Set (MDS) dated [DATE] documents that R75 is cognitively intact. R75's physician orders include an order dated 12/27/2025 for hospice care. R75's progress notes document that R75 has been receiving hospice care since 12/27/2025; however, R75's care plan was not updated until 01/06/2026 to include coordination of care with hospice. [...]

Inspectors wroteBased on observation, Interview, and Record Review the facility failed to accurately assess one resident (R75) of one resident reviewed for smoking and failed to implement interventions to ensure (R75) is safe from hazards associated with smoking without staff knowledge or supervision in a sample list of 38 residents. Findings Include:R75's care plan, updated on 12/27/2025, includes the following diagnoses: chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome. R75's Minimum Data Set (MDS) dated [DATE] documents that R75 is cognitively intact. R75's progress note dated 11/16/2025 at 1:14 PM documents: CNA approached writer at this time reporting smoke coming from the resident's room. CNA reported the smoke smelled like cigarettes. Writer entered the room and observed the resident and a visitor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer enteral feeding as ordered for one (R9) reviewed of one resident reviewed for tube feedings in a sample list of 38. Findings Include:R9's undated care plan documents that R9 was admitted to the facility on [DATE] with the following diagnoses: chronic atrial fibrillation; essential hypertension; gout; dysphagia, oropharyngeal phase; nondisplaced Type II dens fracture, subsequent encounter for fracture with routine healing; maxillary fracture, unspecified side, subsequent encounter for fracture with routine healing; gastroesophageal reflux disease without esophagitis; multiple fractures of the ribs, left side, subsequent encounter for fracture with routine healing; unspecified displaced fracture of the fourth cervical vertebra, subsequent encounter for fracture with routine healing; dysphagia, oral phase; [...]

Inspectors wroteBased on observations, interview and record review the facility failed to ensure resident right to be free from staff to resident (R1) misappropriation of a credit card. R1 is one of three residents reviewed for abuse/misappropriation on the sample list 31. R1 experienced psychosocial harm, including emotional distress and tearfulness, as a direct result of the misappropriation of her credit card.

Inspectors wroteBased on interview and record review the facility failed to safely transport a resident resulting in two falls from the wheelchair. The facility also failed to document fall investigations for two falls. These failures affected one of three residents (R9) reviewed for falls on the sample list of 31. Findings Include:The facility's Accidents and Incidents Policy dated 7/1/23 documents that all accidents or incidents involving a resident will be documented in risk management, and the nursing team will complete an investigation that includes identification of the root cause and implementation of new interventions. R9's undated Medical Diagnoses List documents that R9 was diagnosed with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and unspecified abnormalities of gait and mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to transcribe a physician ordered medication (Coumadin) to prevent blood clot formation, for a resident post-surgical procedure, and an underlying high-risk diagnoses for blood clot formation. This failure resulted in a significant medication error. This failure affected one of 20 residents (R4) reviewed for medications on the sample list of 31.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain residents dignity by failing to provide toileting in a timely manner. This failure affected one of five residents (R1) reviewed for dignity/incontinence care on the sample list of 3.

Inspectors wroteBased on interview and record review the facility failed to report misappropriation of an amethyst stone ring to Illinois Department of Public Health (IDPH), in a timely manner. This failure affected one of four residents (R12) reviewed for abuse/misappropriation on the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to investigate two resident (R1 and R12) allegations of misappropriation. R1 and R12 are two of four residents reviewed for abuse/misappropriation on the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to implement physician's orders for one of three residents (R9) reviewed for following plans of care on the sample list of 31. Findings Include:R9's Hospice admission Orders dated [DATE] document that R9 was admitted to hospice care. To protect R9's skin, staff were instructed to use incontinence pads instead of incontinence briefs. On [DATE] at 1:21 PM, V29, Licensed Practical Nurse (LPN), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9. On [DATE] at 12:52 PM, V45, Certified Nursing Assistant (CNA), stated she was not aware that staff were supposed to use incontinence pads instead of incontinence briefs for R9. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate medical record for one resident (R1) of three residents reviewed for medical records in a sample list of three residents.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from physical abuse for one of four residents (R3) reviewed for abuse in the sample list of eight. Findings Include: The facility's Abuse Policy dated 1/9/24 documents it is the responsibility of the facility staff to assure that all residents remain free from abuse. The facility affirms the right of its residents to be free from abuse. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. Physical abuse is the infliction on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interview the facility failed to provide a dependent resident, who is a two-person assist, a safe transfer in order to prevent a fall. This failure affected one of seven residents (R1) reviewed for falls/safe transfer on the sample list of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper storage of medications and biologicals by allowing non-licensed personnel access to nurses medication rooms and not ensuring nurses medication cart was supervised by a licensed nurse. This failure has the potential to affect all 62 residents residing in facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents residing in the facility.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to maintain infection prevention procedures to provide a sanitary environment during dietary meal services. This failure has the potential to affect all 62 residents residing in the facility. B. Based on observation, interview, and record review the facility failed to follow a physician order for Contact Isolation Precautions for one (R12) resident of one resident reviewed for infection control in a sample list of 28 residents. Findings Include: A. On 2/6/24 at 9:50 AM, V1, Administrator, stated the facility is in outbreak status for Covid-19. On 2/6/24 at 3:15 PM, V2, Director of Nursing/ Infection Preventionist, confirmed the facility was in outbreak status with residents, and staff, testing positive for Covid-19. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain Physician responses to Registered Pharmacist recommendations, failed to implement physician responses, and failed to maintain records of medication regimen review reports. This failure affects three residents (R14, R31, and R48) out of five reviewed for unnecessary medications on the sample list of 28.

Inspectors wroteBased on interview and record review, the facility failed to complete initial and quarterly psychotropic medication assessments, psychotropic Abnormal Involuntary Movement Scale (AIMS), and psychotropic gradual dose reductions for six of seven residents (R8, R27, R29, R31, R48, R168) reviewed for psychotropic medications on the sample list of 28. Findings Include: 1. R29's Medical Diagnoses List, dated February 2024, documents R29 is diagnosed with Dementia, Anxiety, and Major Depression. R29's Physician Order Sheet, dated February 2024, documents orders for Trazodone (Sedative) 50 milligrams at bedtime for Major Depression, Sertraline (Anti-depressant) 25 milligrams daily for Major Depression, and Lorazepam (Anti-anxiety) 0.5 milligrams daily for Anxiety. R29's Medical Record had no record of any Psychotropic Medication Assessments completed for these medications since March 2023. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during incontinence care for one (R5) resident out of one resident reviewed for resident rights in a sample list of 28 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary/recapitulation of stay for one (R64) resident out of one resident reviewed for discharge in a sample list of 28 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement post-fall nursing interventions according to a resident's care plan for fall prevention. This failure affects one resident (R26) out of five reviewed for accidents on the sample list of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change the urinary catheter every 28 days for one resident (R315) out of two residents reviewed for urinary catheters in a sample list of 28 residents. Findings Include: 1. R315's undated Face Sheet documents an admission date of 1/9/24. This same Face Sheet documents R315's medical diagnoses of Urinary Tract Infection, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Type 2 Diabetes Mellitus Without Complications, Bladder-Neck Obstruction, Obstructive And Reflux Uropathy, Hydronephrosis With Renal And Ureteral Calculous Obstruction. R315's Minimum Data Set (MDS), dated [DATE], documents R315 as cognitively moderately impaired. This same MDS documents R315 as requiring maximum one person assist for toileting, bathing, and catheter/perineal care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse for eight consecutive hours a day. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired over the counter cough syrup was discarded and not available for use. This failure had the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that chemical sanitizing agent was being dispensed accurately in the low temperature dish washer to ensure that dishes were properly sanitized. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, a facility employee failed to self report an illness and continued to work in the kitchen, handling ready to eat food products, putting residents at risk for food borne illness. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to designate an individual as Infection Preventionist in the facility who has completed specialized training in infection prevention and control. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of elevated blood glucose levels on 31 separate occurrences for one of two residents (R37) reviewed for insulin use on the total sample list of 29.

Inspectors wrote2.) R97's Medication Administration Record (MAR), dated December 2022, documents R97 receives Amitriptyline Hydrochloride (antidepressant) 25 Milligrams (mg) one tablet by mouth in the evening, Citalopram Hydrobromide (antidepressant) Tablet 20 mg one tablet by mouth in the morning, Seroquel (anti-psychotic) 25 mg two tablets by mouth at bedtime. This MAR documents that these medications are being used for Depression. R97's electronic medical record documents R97 was admitted to the facility on [DATE]. R97's medical record does not contain documentation for the medical rationale of the use of duplicative medications for Depression, or an initial evaluation of R97's use of psychotropic medications. On 12/5/22 at 11:17 AM, V2, Director of Nursing, stated R97's psychotropic medications are for Depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (R16) was not subjected to verbal/mental abuse by a staff member. R16 is one of two residents reviewed for abuse from a sample list of 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a physical restraint assessment demonstrating medical necessity, and failed to attempt less restrictive interventions before applying a physical restraint to one resident (R34) of one resident reviewed for restraints in a sample list of 29 residents. Finding Include: R34's Care Plan, updated 11/2/22, includes the following diagnoses: Generalized Anxiety Disorder, Dementia, Muscle weakness, Psychotic Disturbance, and Gait Abnormalities. R34's Minimum Data Set (MDS), dated [DATE], documents (R34) is severely cognitively impaired and able to walk with assistance of one staff. R34's Care Plan, revised 1/2/22, documents as an intervention under falls, May have (lap top cushion) in place while in wheelchair for safety. R34's most recent restraint evaluation is dated 7/4/22. [...]

Inspectors wroteBased on record review and interview, the facility failed to address a significant weight loss for one resident (R16) and a physical restraint for another resident (R34). This failure effects two of twelve residents reviewed for Care Plans in a sample list of 29. 1.) R16's Care Plan, initiated 9/19/22, includes the following diagnoses: Unsteadiness on Feet, Dementia, Psychotic Disturbance, Anxiety, and Dysphasia. R16's weight tracking, dated 09/19/2022, documents R16 weighed 114 lbs. R16's weight tracking, dated 11/02/2022, documents R16 weighed 107 pounds. This is a 6.14 % weight loss. R16's Care Plan does not address significan weight loss. 2.) R34's Care Plan, updated 11/2/22, includes the following diagnoses: Generalized Anxiety Disorder, Dementia, Muscle weakness, Psychotic Disturbance, and Gait Abnormalities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to cleanse a wound during treatment for one resident (R40) of one resident reviewed for Pressure ulcers in a sample list of 29 residents.

Inspectors wroteBased on interview and record review, the facility failed to investigate the root cause of an incident resulting in a skin tear for one of three residents (R6) reviewed for accidents on the total sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop written resident care policy and procedures for aerosol drug delivery system storage in residents rooms, and failed to ensure personal aerosol drug delivery system equipment was stored properly to prevent cross-contamination for two of two residents (R8 and R15) reviewed for respiratory therapy on the total sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to offer one resident (R40) the opportunity to receive pneumococcal pneumonia vaccination. R40 is one of five residents reviewed for immunizations in a sample list of 29 residents.

Inspectors wroteBased on observation and interview, the facility failed to provide information and post information for contacting the State Survey Agency. This failure has the potential to affect all 43 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post notice of availability of survey results, and failed to post the most up to date survey inspection results in an area accessible to residents and families. This failure has the potential to affect all 43 residents residing in the facility.