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F0659
D

Failure to Communicate and Implement Hospice Care Orders

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 implement a physician's order for a resident who was admitted to hospice care, specifically regarding the use of incontinence pads instead of incontinence briefs to protect the resident's skin. Multiple staff members, including LPNs and CNAs, reported they were not aware of the order and continued to use incontinence briefs for the resident until the resident's death. The Director of Nursing confirmed uncertainty about whether the order had been communicated to nursing or CNA staff and acknowledged that this information should have been shared and followed.

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