Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mt Zion Health & Rehab Center during CMS and state inspections, most recent first.
Failure to follow a fall care plan intervention for a resident at high risk for falls. The resident had multiple diagnoses including Alzheimer's disease, hemiplegia, subdural hemorrhage, and a history of falls, and the care plan required non-skid socks at all times. Staff transferred the resident with a mechanical lift while the resident was not wearing non-slip socks, and the resident was later observed without them again. The resident also reported recently falling out of bed while sleeping.
Failure to obtain an ordered BMP for a resident with recent hyponatremia and multiple neurologic and fracture diagnoses. The resident returned from the hospital with discharge instructions for a BMP, but the lab result was not in the chart. The DON said the resident refused blood draws and the MD was aware, but there was no documentation of refusal or MD notification; the resident denied refusing labs, an RN confirmed no refusal, and the MD stated being unaware the BMP order had not been completed.
A high fall-risk resident with moderate cognitive impairment, generalized weakness, pneumonia, dementia, and COPD, who required supervision for transfers and did not ambulate due to safety concerns, had a care plan and fall risk assessment calling for the bed to be kept in the lowest position and a floor mat placed at bedside. On the day of the incident, staff and the roommate reported the bed was at about knee height and no floor mat was in place, despite the Kardex and care plan requiring it. The resident was seen sitting on the edge of the bed shortly before being found on the floor next to the bed with severe right hip pain, after reportedly attempting to get up, and an X-ray later showed an acute, mildly displaced fracture of the right greater trochanter.
The facility failed to protect a resident from physical abuse when another resident with a history of agitation and attempts to hit staff approached and struck the resident multiple times with a closed fist in a hallway. The abused resident, who had GAD, major depressive disorder, Parkinson’s disease, and moderately impaired cognition, remained seated, reported feeling scared, and cried briefly during the incident. A CNA witnessed the assault, noting that the aggressive resident often became overwhelmed by noise and agitated, but had not previously been seen hitting other residents.
The facility failed to implement a Legionella surveillance program and failed to properly sanitize a glucometer after use on a resident. The Maintenance Director stated he only checked faucets for rust and was not aware of Legionella testing or the CDC questionnaire, while the Corporate Maintenance Director confirmed the policy was not being followed. In a separate event, an LPN performed a BG check, then wiped the glucometer for only a few seconds instead of the required 3-minute contact time before returning it to the med cart for use on other residents.
Failure to Protect Resident from Resident-to-Resident Physical Abuse: A resident with severe cognitive impairment and a care plan for potential physical aggression pulled another resident’s hair during a resident-to-resident altercation. The affected resident reported the hair-pulling and believed some hair was missing, and an LPN stated the other resident admitted to the act while being loud and fussy that evening. The DON acknowledged the incident and agreed residents have the right to be free from abuse.
Failure to report a resident-to-resident abuse allegation to IDPH. A resident with moderate cognitive impairment but clear speech reported that another resident kicked her leg under a dining room table and she immediately told staff. An RN said she knew about the incident and informed the former Administrator, but there was no EMR documentation, the DON was not aware of the allegation until later, and the incident was not investigated or reported as required.
Failure to provide nail care for a resident dependent on staff for ADLs. The resident had severe cognitive impairment and required assistance with personal hygiene per the MDS and care plan. The resident’s daughter reported the fingernails were often overgrown and dirty, and surveyors observed dark brown debris under all fingernails. The AD stated nail care is typically done weekly and CNAs and nursing staff are responsible for daily nail care needs; the DON stated staff should check nails daily and address dirt under the nails.
The facility failed to coordinate hospice care with the hospice provider for a resident receiving hospice services. The resident had multiple diagnoses, was cognitively intact, and had physician orders for hospice, but the care plan was not updated to include hospice coordination until after hospice had already been in place. The DON confirmed the care plan addressing hospice coordination was not in place when expected.
Failure to Assess and Supervise Resident Smoking Behavior: A cognitively intact resident with multiple diagnoses was documented as not smoking on the smoking assessment, yet staff later found cigarette smoke in his room, observed him smoking with a visitor, and later saw him smoking outside while wearing oxygen. The resident stated he would smoke if he wanted to and that a woman would bring him cigarettes, while the Administrator verified the facility was smoke-free and that the care plan should have included specific interventions to address the smoking behavior.
A resident with a G-tube and multiple diagnoses including dysphagia had an order for Jevity 1.5 at 70 mL/hr for 20 hours, with the pump to stop at 8:00 AM and restart at 12:00 PM. The MAR entries did not total the ordered fluid amount, and the resident was observed still attached to the pump after the scheduled stop time with 1,546 mL of feed and 775 mL of flush infused. The resident reported the pump had been beeping for some time, staff added water to the flush bag, and the pump was left running; the DON acknowledged the error.
A resident with no cognitive impairment suffered emotional distress after a CNA stole and used her credit card for over $1,000 in unauthorized purchases. The CNA was arrested following a police investigation, but staff reported no internal investigation was conducted at the time, and the facility lacked an Administrator during the incident.
A resident with Alzheimer's disease and high fall risk experienced two falls from a wheelchair during transport when staff proceeded despite the resident leaning forward and attempting to stand. The facility also failed to complete required fall investigations for two of the resident's falls, as confirmed by the DON.
A resident with multiple cardiac conditions and recent orthopedic surgery did not receive physician-ordered Coumadin for 14 days due to a failure by an LPN to transcribe the medication order into the electronic record. The medication was available at the facility, but the omission was not identified by other nursing staff, resulting in missed anticoagulation therapy until the medical director discovered the error during rounds.
A resident who was cognitively intact and typically continent requested toileting assistance before breakfast but was refused by a CNA delivering meal trays, who told the resident to urinate in her brief instead. The resident was left in urine for an extended period, causing emotional distress and humiliation. Staff interviews confirmed the incident and that facility policy requiring prompt response to resident needs was not followed.
A resident with severe cognitive impairment reported a missing amethyst ring, which was a birthday gift from family. Multiple staff, including CNAs and the Social Service Director, were informed and searched for the ring, but no timely report or investigation was made to IDPH as required by facility policy. The incident was not documented in reportable or grievance logs, and the family received no follow-up until weeks later when a new Administrator became involved.
Two residents' allegations of misappropriation were not investigated by facility staff as required by policy. One resident's credit card was stolen and used by a CNA, but key witnesses were not interviewed and no internal investigation was conducted. In a separate incident, a cognitively impaired resident's missing ring was reported by family and staff, but no investigation or state report was initiated until prompted by surveyors. The facility failed to follow its abuse policy, resulting in delayed identification and investigation of both incidents.
A resident admitted to hospice care had physician orders for staff to use incontinence pads instead of incontinence briefs to protect skin integrity. Multiple staff members, including an LPN and CNAs, were unaware of this order and continued using incontinence briefs until the resident's death. The DON confirmed the order may not have been communicated to staff and acknowledged it should have been followed.
A resident with a history of stroke, left-sided weakness, and other medical conditions was transported in a wheelchair without foot pedals, resulting in her weak leg becoming caught in the wheel and causing a fall that led to a nasal bone fracture. Staff confirmed the absence of footrests during transport, and the facility lacked a policy on their use.
A resident with multiple diagnoses and a high fall risk experienced a significant fall resulting in facial injuries. There were conflicting accounts from the resident, a dietary aide, a physical therapy assistant, and an LPN regarding whether wheelchair footrests were in place at the time of the fall. Documentation in the medical record and the incident report submitted to the state agency were inconsistent, and the LPN who documented the event was not listed as a witness. The administrator acknowledged awareness of these discrepancies, indicating a failure to maintain an accurate and consistent medical record.
A resident with a history of trauma and mental health conditions was physically assaulted by another resident with severe cognitive impairment, who struck her in the arm and attempted to pull her from her chair in the dining room. Staff intervened after the incident, but the assaulted resident reported feeling unsafe for several days. The facility's abuse policy requires protection from such incidents, but this event demonstrated a failure to prevent physical abuse.
A resident with a history of falls and multiple health conditions was transferred to a wheelchair by CNAs using a bed sheet sling after an unwitnessed fall, without a nurse's assessment. The resident, who was cognitively intact, later complained of severe hip pain and was diagnosed with a fractured hip. This action was against the facility's policy, which requires a nurse's assessment before moving a fall victim.
A resident with significant medical conditions and on hospice care fell and sustained injuries due to a single CNA attempting a transfer that required two-person assistance. The CNA did not lock the wheelchair, and the resident fell forward, resulting in a nosebleed, a bruise, and a skin tear. The incident was witnessed by the resident's roommate, who reported inappropriate behavior by the staff after the fall. The facility's DON confirmed that the resident required two-person assistance, which was not provided.
Failure to Follow Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention for a resident who was at high risk for falls. The resident had multiple diagnoses including maxillary fracture, left lateral orbital fracture, hyponatremia, left-sided hemiplegia/hemiparalysis, Alzheimer's disease, subdural hemorrhage, metabolic encephalopathy, depression, and insomnia. The resident's fall care plan, initiated on 7/4/2025, identified fall risk related to medications, Alzheimer's disease, depression, and history of falls, and included an intervention that the resident always have non-skid socks on. The resident's care plan also documented transfers with a mechanical lift. A facility incident report documented that on 3/31/2026 at 6:55 AM, the resident sustained an unwitnessed fall resulting in left orbital and left maxilla fractures, was hospitalized for hyponatremia, and received sutures to the left lateral eye with facial bruising. During observation on 5/26/2026, the resident was transferred from bed to wheelchair by two CNAs using a mechanical lift and did not have non-slip socks on. The resident was later observed without non-skid socks on again on 5/27/2026 and 5/28/2027. The resident stated they recently fell out of bed while sleeping, and a CNA stated they did not place non-skid socks on the resident because the resident does not stand. The facility's fall policy states that if falling occurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions, or indicate why the current approach remains relevant.
Failure to Obtain Ordered BMP
Penalty
Summary
The facility failed to follow a physician order to obtain a BMP for one resident who had been hospitalized for hyponatremia and returned to the facility with discharge instructions that included a BMP to be collected on April 10, 2026. The resident’s record did not contain BMP results. The resident’s medical history included maxillary fracture, left lateral orbital fracture, hyponatremia, left-sided hemiplegia/hemiparalysis, Alzheimer’s disease, insomnia, subdural hemorrhage, metabolic encephalopathy, and depression. During interviews, the lab technician stated the resident’s last BMP had been collected in April 2025. The DON stated the lab draw process was to enter the order into the chart, send it to the lab company, and have the lab technician collect the specimen as scheduled, with results communicated to the physician. The DON later stated the resident did not have the BMP drawn because the resident refused blood draws and that the physician was aware, but there was no documentation in the resident’s record of refusal or physician notification. The resident stated the resident never refuses blood draws, and a registered nurse confirmed the resident did not refuse the blood draw on May 27, 2026. The physician later stated being unaware of the BMP order at discharge and unaware that it had not been processed or completed.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate supervision and implementation of care-planned fall interventions for a resident identified as a high fall risk. The facility’s Fall Prevention Program/Protocol required individualized fall prevention plans, completion of fall risk assessments, and implementation of resident-specific interventions, including visual identifiers and accessible fall intervention information. The policy also required that residents identified as high risk (score ≥10) have visual identifiers and that staff implement interventions based on fall assessments and history of falls. The resident’s fall risk assessment identified them as high risk, and the care plan, initiated earlier in the year, documented multiple prior falls and specified interventions such as maintaining the bed in the lowest position and placing a floor mat next to the bedside. The resident had moderate cognitive impairment, generalized weakness, pneumonia, dementia, and COPD, and the MDS documented that the resident required supervision or touching assistance for transfers and did not ambulate 10 feet due to medical or safety concerns. The care plan documented prior falls on several dates and included an intervention, dated in January, to keep the bed in the lowest position and, dated in March, to place a floor mat next to the bed. On the day of the incident, documentation and staff interviews consistently described the bed as approximately knee height and confirmed that no floor mats were in place at the time of the fall, despite the care-planned intervention and Kardex indicating that mats were required. Staff also reported that the resident was a known fall risk with a history of previous falls. On the date of the fall, the resident was last seen in bed or sitting on the edge of the bed shortly before being found on the floor. A state report and staff interviews indicated that the resident was discovered on the floor next to the bed, lying on the right side or back, complaining of severe right hip pain rated 10/10. The roommate reported that the resident had been sitting on the side of the bed attempting to go to the bathroom and slipped off, and also stated that no fall mats were present at the time, noting that mats were only placed afterward. A CNA in training observed the resident sitting on the edge of the bed and did not intervene, and the DON later stated that the CNA should have responded to the resident sitting on the side of the bed and recognized that fall interventions were not in place. An X-ray documented an acute, mildly displaced fracture of the right greater trochanter following this fall.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident approached another in a hallway and struck them multiple times. The facility’s abuse policy dated 1/9/2024 states that residents have the right to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services, and mistreatment, and that such conduct is prohibited. Despite this policy, on 3/5/2026, one resident (R2) approached another resident (R1) in the facility hallway and struck R1 in the arm twice. R1’s medical record shows diagnoses of Generalized Anxiety Disorder, Major Depressive Disorder, and Parkinson’s Disease, and a resident assessment dated 5/8/2025 documents that R1 has moderately impaired cognition. According to the facility’s abuse investigation file and staff interview, a CNA (V3) observed R2 strike R1 with a closed fist in the upper right arm and, as V3 began to intervene, R2 struck R1 again with a closed fist in the lower right forearm. V3 reported that R2 had been kind of aggressive toward staff during care, would become overwhelmed with noise and agitated, and had previously tried to hit staff, although V3 had not seen R2 hit another resident before. V3 stated that R1 remained seated during the incident, expressed feeling scared, and cried a little but was not completely distraught. The incident involved two residents reviewed for abuse out of a sample of four, and demonstrates that the facility did not prevent one resident from physically abusing another despite known agitation and prior attempts by R2 to hit staff.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to implement a Legionella surveillance program. The facility’s CMS-671 dated 01/05/2026 documented 64 residents, and the facility policy titled Infection Prevention & Control: Legionnaires’ Disease stated that the facility had formed a Water Management Program Committee and maintained an active water management program. On 01/07/2026 at 11:00 AM, the Maintenance Director stated he checked water at faucets monthly and looked for rust, but was not aware of any testing, high-risk areas for Legionella growth, or the CDC Legionella Questionnaire, and denied that any Legionella testing was being conducted. On 01/07/2026 at 1:00 PM, the Corporate Maintenance Director stated that the Maintenance Director had been given a test kit and that the facility had a policy and checklist that should have been completed, and verified that the policy was not being followed. The facility also failed to appropriately sanitize a glucometer after use for one resident. On 01/07/2026 at 11:45 AM, an LPN removed a glucometer from the medication cart, went to the resident’s room, and performed a blood glucose check, then returned the contaminated glucometer to the medication cart. The bleach wipes on the cart documented a required contact time of three minutes for sanitizing a surface, but the LPN wiped the glucometer for only a few seconds and placed it back in the medication cart drawer for use on other residents. When asked about the required contact time, the LPN stated, “I thought I just have to wipe it off.”
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The abuse policy defined abuse as physical or mental injury or sexual assault inflicted by means other than accidental, and defined physical abuse as the infliction of injury that occurs by means other than accidental and requires medical attention. The deficiency involved two residents, one of whom had severe cognitive impairment and a care plan identifying a potential for physical aggression, including grabbing, hitting, kicking, and punching related to Alzheimer’s disease or other dementias, cognitive impairment, depression, and mental illness. An investigation report documented that the two residents were involved in a resident-to-resident altercation when one resident reported that the other pulled her hair. The residents were immediately separated and an investigation was initiated. The affected resident later stated she remembered the incident and gestured to the right side of her head, and her EMR documented that she came to her door yelling that her roommate had pulled her hair so hard that she believed some of her hair was missing. An LPN stated she observed the resident yelling about the hair-pulling, asked the other resident about it, and that resident admitted pulling the hair. The LPN also reported the other resident had been fussing, speaking loudly, and in a fussy mood throughout the evening, and the DON acknowledged awareness of the incident and agreed residents have the right to be free from abuse.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state for two residents reviewed for abuse. The facility’s Abuse Policy stated that all allegations of abuse must be immediately reported to the Administrator/Abuse Coordinator and timely reported to the appropriate authorities, including the Illinois Department of Public Health (IDPH), and that all allegations must be thoroughly investigated and documented. The report identified that the facility did not have documentation in the electronic medical record for the alleged incident involving R66 and another resident. R66’s MDS documented moderate cognitive impairment, but also indicated that she had clear, intelligible speech, could make herself understood, and comprehended others. R66 stated that while eating in the dining room, another resident kicked her right leg under the table and that she immediately told staff. V4, RN, stated she was aware of the incident and identified the other resident as R61, who later passed away, and said R66 was moved to another table after the incident. V4 stated she informed the former Administrator but was unsure what action was taken. The DON stated she was not aware of the allegation until informed during the morning meeting and agreed the incident should have been documented and investigated when it was reported.
Failure to Provide Nail Care for a Resident Dependent on Staff for ADLs
Penalty
Summary
The facility failed to provide nail care to a resident who was dependent on staff for assistance with ADLs. The facility’s ADL Support Policy states that residents who are unable to perform ADLs independently will receive services necessary to maintain grooming and personal hygiene, and that residents’ needs should be addressed in accordance with the care plan. R54’s MDS documented severe cognitive impairment and need for partial to moderate assistance with self-care for personal hygiene tasks, and the care plan identified a self-care deficit related to Alzheimer’s disease, COPD, asthma, and osteoarthritis, with one-person physical assistance required from staff for ADLs including personal hygiene. The resident’s daughter and POA stated that the resident’s fingernails were often overgrown and dirty and that the facility had been made aware of the concern numerous times. During observation, the resident was seen with dark brown debris under all fingernails and was unable to recall when nail care was last performed. The Activity Director stated that nail care is typically performed weekly in the Activity Department and that CNAs and nursing staff are responsible for daily nail care needs, and agreed that the resident’s nails required cleaning. The DON stated that staff should observe residents during morning care and check nails daily, and agreed that nail care should be addressed when dirt is observed under a resident’s fingernails.
Failure to Coordinate Hospice Care in the Care Plan
Penalty
Summary
The facility failed to coordinate hospice care with the hospice provider for one resident receiving hospice services. The resident had diagnoses including chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome, and the MDS documented that the resident was cognitively intact. Physician orders included hospice care, and progress notes showed the resident had been receiving hospice care since 12/27/2025; however, the care plan was not updated until 01/06/2026 to include coordination of care with hospice. On 01/05/2026, the DON verified that the resident had been on hospice since 12/27/2025 and confirmed that a care plan addressing coordination of hospice care with the provider was not in place, stating that the facility expected a resident-centered care plan when a resident is placed on hospice.
Failure to Assess and Supervise Resident Smoking Behavior
Penalty
Summary
The facility failed to accurately assess one resident and failed to implement interventions to keep that resident safe from hazards associated with smoking without staff knowledge or supervision. The resident, R75, had diagnoses including chronic atrial fibrillation, obsessive-compulsive disorder, anxiety disorder, lumbar osteomyelitis, and chronic pain syndrome, and was documented as cognitively intact on the MDS. The resident’s safe smoking assessment stated that he did not smoke, had never smoked, and did not sign a smoking contract, yet the record later documented multiple smoking-related incidents involving the resident and visitors bringing cigarettes into the room. On 11/16/2025, staff observed smoke coming from R75’s room, smelled cigarette smoke, and found ashes on the bed; the resident stated he had smoked a cigarette brought by a visitor. On 01/01/2026, staff observed R75 and his girlfriend smoking outside with oxygen on and in his nose, despite being told the facility was non-smoking. On 01/05/2026, the resident stated he would smoke if he felt like it and that his woman would bring him cigarettes. The Administrator later verified that the facility was smoke-free and that R75’s care plan should have included specific interventions to protect him and other residents from hazards related to smoking without staff knowledge or observation.
Enteral Feeding Not Administered as Ordered
Penalty
Summary
The facility failed to administer enteral feeding as ordered for one resident with a gastrostomy tube. The resident was admitted with multiple diagnoses including dysphagia, chronic atrial fibrillation, hypertension, gout, gastroesophageal reflux disease, hypothyroidism, pulmonary fibrosis, and multiple healed fractures. The physician order dated 11/12/2025 directed Jevity 1.5 to be infused via enteral pump at 70 mL per hour for 20 hours, totaling 1,400 mL, with the pump to be disconnected at 8:00 AM and restarted at 12:00 PM. The resident’s MAR for December documented twice-daily nursing entries with recorded amounts that did not total the ordered 2,300 mL of fluid per day. On 01/05/2026 at 11:30 AM, the resident was observed connected to the tube feeding pump, which displayed 1,546 mL of feed infused and 775 mL of flush infused. The resident stated the pump should have been shut off at 8:00 AM and had been beeping for some time; staff reportedly added water to the flush bag but left the pump running. The DON stated the pump should have been shut off after 1,400 mL of tube feeding had infused, and later acknowledged the errors. The facility policy stated the nurse is responsible for confirming that enteral nutrition is completed as ordered and accurately documented.
Failure to Prevent Misappropriation of Resident's Credit Card by CNA
Penalty
Summary
A facility failed to protect a resident from the misappropriation of her credit card by a Certified Nursing Assistant (CNA). The resident, who was cognitively intact with a BIMS score of 15, experienced emotional distress and tearfulness after her credit card was stolen and used for unauthorized purchases totaling $1,350.01. The CNA was arrested by local police, and the investigation was supported by evidence including camera footage and messages from the CNA apologizing for the theft. The incident was confirmed by both the police department and facility staff interviews. At the time of the incident, the facility did not have an Administrator in place, and there was no evidence that an internal investigation was conducted by the previous Administrator. Staff, including an LPN, reported being unaware of any investigation or being interviewed about the theft. The facility's abuse policy assigns responsibility for abuse prevention and reporting to the Administrator or designee, but this protocol was not followed in this case, resulting in the resident experiencing psychosocial harm.
Failure to Safely Transport Resident and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure safe transport and adequate supervision for a resident with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and gait abnormalities, who was identified as a high fall risk. The resident experienced three falls in one month, two of which occurred during transport in a wheelchair when staff members pushed the resident forward despite her leaning forward and attempting to stand. Both CNAs involved confirmed that the resident frequently leaned forward and tried to stand while seated, and that they proceeded with transport under these conditions, resulting in the resident falling forward out of the wheelchair. One of these falls resulted in a hematoma to the resident's forehead. Additionally, the facility did not complete required fall investigations for two of the resident's falls, as mandated by their Accidents and Incidents Policy. The Director of Nursing confirmed that staff should not have transported the resident while she was leaning forward or attempting to stand, and acknowledged that fall investigations were not conducted for two incidents. These failures affected one resident reviewed for falls out of a sample of 31.
Failure to Transcribe and Administer Physician-Ordered Anticoagulant
Penalty
Summary
A significant medication error occurred when a physician-ordered anticoagulant, Coumadin, was not transcribed into the facility's electronic medical record for a resident who had recently undergone left femur fracture surgery (ORIF) and had multiple high-risk cardiac diagnoses, including atrial fibrillation and cardiomyopathy. The hospital discharge instructions specified that Coumadin therapy should be continued, with a detailed dosing schedule, and the medication was delivered to the facility and available for administration. However, the Coumadin order was not entered into the Physician Order Sheet upon admission, resulting in the medication not appearing on the Medication Administration Record (MAR) and not being administered by nursing staff. The error was traced to an LPN who admitted the resident and failed to transcribe the Coumadin order, citing confusion regarding the dosing schedule. This omission was not identified by subsequent nursing staff, as there was no verification or follow-up on the admission orders or discharge instructions. As a result, the resident missed 14 consecutive days of prescribed anticoagulation therapy. The error was only discovered when the medical director, during rounds, noticed the absence of anticoagulation therapy and intervened. Documentation from the facility's pharmacy confirmed that the Coumadin prescription matched the hospital discharge orders and was available for use. The medical director and pharmacist both acknowledged that the missed doses posed a significant risk to the resident, given their recent surgery and underlying cardiac conditions. The incident was recorded in the facility's Quality Assurance report, which also noted an additional transcription error regarding the Coumadin dosing schedule.
Failure to Provide Timely Toileting Assistance and Maintain Resident Dignity
Penalty
Summary
A deficiency occurred when a staff member failed to provide timely toileting assistance to a resident who was cognitively intact and typically continent of bowel and bladder, but required substantial assistance for transfers. The resident requested to be taken to the bathroom before breakfast, but the Certified Nursing Assistant (CNA) delivering the meal tray refused, stating she was not assigned to the resident and was too busy, and told the resident to urinate in her incontinence brief. As a result, the resident was left sitting in urine for an extended period, which caused her significant emotional distress and humiliation. The incident was corroborated by the resident's roommate and another CNA, both of whom confirmed the resident's upset state and the inappropriate response from the staff member. Further interviews with staff revealed that the CNA responsible for delivering trays did not assist the resident or ensure that another staff member promptly addressed the toileting request. The resident's incontinence brief was found to be dry when she was later assisted to the bathroom, confirming her usual continence when toileted in a timely manner. The facility's policy requires all staff to treat residents with dignity and to respond to their needs regardless of assignment, but this was not followed in this instance, resulting in a failure to maintain the resident's dignity and respect.
Failure to Timely Report and Investigate Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report the suspected misappropriation of a resident's amethyst stone ring to the Illinois Department of Public Health (IDPH) in a timely manner. The incident involved a resident with severe cognitive impairment, whose family had gifted her the ring for her birthday. The ring was last seen before Thanksgiving, and its disappearance was reported by the resident's family member to staff. Multiple staff members, including CNAs and the Social Service Director, were made aware of the missing ring, and some staff conducted a search of the resident's room. However, there was no documentation of an investigation or timely reporting to IDPH at the time the ring was discovered missing. Interviews revealed that staff were aware of the missing ring and discussed it in morning meetings, but there was confusion regarding who was responsible for reporting and investigating the incident. The Director of Nursing assumed the Social Service Director had reported and investigated the matter, while the Social Service Director did not consider the missing ring as abuse and did not log or report it. The CNA who initially received the report wrote a statement and submitted it as instructed, but was not contacted for further details. The family member of the resident did not receive any follow-up from the facility until weeks later, after the new Administrator became involved. The facility's own abuse policy requires all allegations of abuse, including misappropriation of property, to be reported immediately to the Administrator and in a timely manner to appropriate authorities such as IDPH. Despite this policy, the missing ring was not reported or investigated as required, and the incident was not documented in the facility's reportable or grievance logs. The lack of timely reporting and investigation resulted in a deficiency related to the facility's failure to follow its abuse prevention and reporting procedures.
Failure to Investigate Allegations of Misappropriation
Penalty
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.
Failure to Communicate and Implement Hospice Care Orders
Penalty
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.
Resident Injury Due to Improper Wheelchair Transport
Penalty
Summary
A resident with multiple diagnoses, including osteoporosis, left hemiparesis, Parkinson's disease, and a history of stroke, was identified as high risk for falls. The resident was being transported in a wheelchair without foot pedals in place. During this transport, the resident's weak leg became caught in the front wheel of the wheelchair, causing the resident to fall forward onto her face and sustain a bilateral nasal bone fracture and soft tissue hematoma. The resident reported significant pain, anxiety, and visible injuries following the incident. Staff interviews confirmed that the footrests were not attached to the wheelchair at the time of the fall, and that the resident's foot became entangled in the wheel, leading to the accident. The acting DON stated that it was her expectation that foot pedals should be in place when transporting residents in wheelchairs. The facility did not provide a policy regarding the use of foot pedals during transport. This failure to ensure proper use of wheelchair footrests resulted in the resident's injury.
Failure to Maintain Accurate Medical Record Following Resident Fall
Penalty
Summary
The facility failed to maintain an accurate and consistent medical record for a resident with multiple diagnoses, including osteoporosis, anxiety disorder, left hemiparesis, major depression, delusional disorder, history of right shoulder replacement, Parkinson's disease, type II diabetes, and a history of cerebral infarction. The resident was identified as high risk for falls and was cognitively intact. The resident experienced a significant fall resulting in bilateral nasal bone fracture and a soft tissue hematoma, as confirmed by a CAT scan. Multiple staff interviews and documentation revealed discrepancies regarding the presence of footrests on the wheelchair at the time of the fall. The resident and a dietary aide both stated that neither footrest was in place, and the resident's weak leg became caught in the front wheel, causing her to fall face-first. A physical therapy assistant also indicated that the footrests were not in use at the time of the incident. However, the progress note by an LPN documented that the resident's foot fell off the footrest, causing the fall, while the facility's final incident report to the state agency stated that the foot pedals were in place. The LPN who wrote the progress note was not listed as a witness on the incident report. When questioned about these discrepancies, the administrator acknowledged awareness of the inconsistent documentation and related issues. These conflicting accounts and documentation errors demonstrate the facility's failure to maintain an accurate and reliable medical record for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of depression, general anxiety disorder, PTSD, and prior experiences of abuse was physically assaulted by another resident diagnosed with dementia and severe cognitive impairment. The incident occurred when the resident with dementia approached the other resident in the dining room, demanded her seat, and, upon refusal, struck her in the left arm with a closed fist and attempted to pull her out of her chair. The assaulted resident called for staff, who intervened and separated the two individuals. The assaulted resident was visibly upset and reported feeling unsafe for several days following the incident. The care plan for the assaulted resident documented her vulnerability to abuse due to her medical and trauma history, including frailty and prior abuse. Staff interviews confirmed the sequence of events, and a witness corroborated that the physical assault took place. The facility's abuse policy requires staff to ensure residents remain free from abuse, but the incident demonstrated a failure to protect the resident from physical harm by another resident.
Failure to Assess Resident Before Transfer After Fall
Penalty
Summary
The facility failed to properly assess a resident before transferring them to a wheelchair following a fall. This incident involved a resident who was cognitively intact and had a history of conditions such as Metabolic Encephalopathy, Hypertension, Coronary Artery Disease, and Multiple Sclerosis, which increased their risk for falls and injuries. After the resident was found crawling on the floor by a CNA, they were transferred to a wheelchair using a bed sheet as a sling without being assessed by a nurse. The resident complained of severe hip pain and was later diagnosed with a fractured right hip at the hospital. The facility's policy on accidents and incidents clearly states that a victim should not be moved until they have been examined for possible injuries. However, in this case, the CNAs moved the resident without notifying a nurse first, which was against the policy. The nurse was only informed after the resident had already been transferred to the wheelchair. The facility's administration acknowledged that the resident should not have been moved without a nurse's assessment, indicating a breach in protocol.
Failure to Provide Safe Transfer for Dependent Resident
Penalty
Summary
The facility failed to provide a dependent resident, who required a two-person assist, with a safe transfer, resulting in a fall. The resident, who had significant medical conditions including Chronic Myelocytic Leukemia, COPD, diabetes, and hypertension, was on hospice care and had been experiencing a rapid decline in health. The resident's care plan clearly indicated the need for two-person assistance for transfers and toileting, which was not followed during the incident on 4/14/24. The resident fell forward out of a wheelchair while being assisted by a single CNA, resulting in injuries including a nosebleed, a bruise on the forehead, and a skin tear on the left forearm. The CNA did not lock the wheelchair, and the resident, who was already weak and dizzy, fell face forward onto the floor. The incident was witnessed by the resident's roommate, who confirmed that only one CNA was assisting the resident and that the wheelchair was not locked. The roommate also reported that the CNA and another staff member were laughing and talking inappropriately after the fall. The facility's Director of Nursing confirmed that the resident should have been on complete bedrest and required two-person assistance for any necessary transfers, which was not adhered to at the time of the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 176 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Zion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Imboden Creek Senior Living | 4.8 mi | ★★★★★ | 36 | 1 |
| Fair Havens Senior Living | 6 mi | ★★★★★ | 33 | 1 |
| Loft Rehab Of Decatur | 7.5 mi | ★★★★★ | 26 | 0 |
| Loft Rehab Of Rock Springs, The | 7.6 mi | ★★★★★ | 16 | 0 |
| Decatur Rehab & Health Care Ct | 7.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.