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F0610
D

Failure to Investigate Allegations of Misappropriation

Mount Zion, Illinois Survey Completed on 12-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate allegations of misappropriation involving two residents. One resident, who was cognitively intact, reported the theft of her credit card, which was later confirmed by a police investigation to have been used fraudulently by a CNA. Despite the resident and her roommate both having knowledge of the incident, the facility's Regional Nurse Consultant did not conduct an internal investigation or interview key witnesses, citing workload as the reason for inaction. The roommate, who was present during the suspected theft, was never interviewed by facility staff, and her knowledge of another misappropriation event involving a different resident was also not solicited. Another resident, who had severe cognitive impairment, was reported by her family to have lost a ring of significant sentimental value. The DON recalled hearing about the missing ring in a morning meeting but did not initiate an investigation or notify authorities, assuming another staff member would handle it. The Social Service Director, although aware of the missing ring, did not investigate because she was not directed to do so by the interim administrator. Multiple staff members and the resident's family reported the missing ring, but no formal investigation or report to the state health department was made until prompted by the survey process. The facility's own abuse policy requires immediate and thorough investigation of all allegations of misappropriation, including interviews with all relevant parties. However, in both cases, the facility failed to follow its policy, resulting in delayed identification and investigation of the incidents. Documentation of investigations was lacking, and key witnesses were not interviewed, leading to a failure to respond appropriately to the alleged violations.

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