Mt Zion Health & Rehab Center
MT ZION HEALTH & REHAB CENTER in MOUNT ZION, IL — inspection on May 28, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
prevent accidents.
observation, interview and record review the facility failed to implement a fall care plan intervention
include:R2's Medical Record documents R2 was admitted to the facility on [DATE]. R2's Medical Record includes the following diagnoses: Maxillary Fracture, Left Lateral Orbital Fracture, Hyponatremia, Left-Sided Hemiplegia/Hemiparalysis, Alzheimer's Disease, Insomnia, Subdural Hemorrhage, Metabolic Encephalopathy, Depression, and Insomnia. R2's Fall Care Plan initiated 7/4/2025 documents R2 is at risk for falls related to medications, Alzheimer's Disease, Depression, and History of Falls. R2's Care Plan documents R2 transfers with a mechanical lift and includes an intervention for R2 to always have non-skid socks on.A facility reported incident documents on 3/31/2026 at 6:55 AM, R2 sustained an unwitnessed fall resulting in left orbital and left maxilla fractures. R2 was admitted to the hospital following the fall due to hyponatremia and received sutures to the left lateral eye with facial bruising.R2's Fall Risk assessment dated [DATE] documents R2 as at high risk for falls.On 5/26/2026 at 12:45 PM, V6 (Certified Nursing Aids, CNA) and V11 (CNA) used a mechanical lift to transfer R2 from the bed to the wheelchair. R2 did not have non-slip socks on. On 5/27/2026 at 10:00 AM, R2 was observed without non-skid socks on. On 5/28/2027 at 10:00 AM, R2 was observed without non-skid socks on.On 5/26/2026 at 10:20 AM, R2 stated R2 recently fell out of bed while sleeping. On 5/26/2026 at 11:00 AM, V6 (CNA) stated they do not place non-skid socks on R2 because R2 doesn't stand.The facility's Fall Policy dated 9/6/2023 documents if falling occurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions, or indicate why the current approach remains relevant.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145546 05/28/2026
MT Zion Health & Rehab Center 1225 Woodland Drive Mount Zion, IL 62549
one (R2) of three residents reviewed for accidents in the sample of three.
Findings include:R2's
documents the following diagnoses: Maxillary Fracture, Left Lateral Orbital Fracture, Hyponatremia, Left-sided Hemiplegia/Hemiparalysis, Alzheimer's Disease, Insomnia, Subdural Hemorrhage, Metabolic Encephalopathy, Depression, and Insomnia. R2's Progress Note dated 3/31/2026 documents R2 was sent to a local hospital and was admitted for hyponatremia. R2's Discharge Instructions dated 4/3/26 document R2 returned to the facility on 4/3/2026.R2's Discharge Instructions dated 4/3/2026 included an order for a Basic Metabolic Panel (BMP) to be collected on April 10th, 2026. R2's Medical Record does not contain BMP results. On 5/26/2026 at 10:45 AM, V29 (Lab technician) stated R2's last BMP was collected in April 2025. On 5/27/2026 at 10:15 AM, V2 (DON) stated the process for lab (laboratory) draws is to enter the order into the medical chart.
The order is sent to the lab company.
The lab technician comes when the order is scheduled and collects the specimen. V2 (DON) stated it is expected for lab results to be communicated to the physician.On 5/27/2026 at 11:00 AM, V2 (DON) stated the reason R2 did not have a BMP drawn was because R2 refused blood draws. V2 (DON) stated V27 (Physician) was aware. No documentation is present in R2's Medical Record regarding R2 refusing labs or notification to the physician. On 5/27/2026 at 11:45 AM R2 stated R2 never refuses blood draws for labs. On 5/27/2026, a STAT BMP order was placed in R2's Physician Orders. On 5/27/26 at 12:10 PM V26 Registered Nurse confirmed R2 did not refuse the blood draw on 5/27/26. On 5/27/2026 at 1:55 PM V27 stated V27 was unaware that R2 had orders for a BMP (Basic Metabolic Panel) at the time of discharge and was unaware those orders were not processed or completed.
The facility policy for Obtaining Blood Specimens dated 7/2/2023 documents laboratory results and notification of physician of results should be recorded in the resident's medical record.
The policy documents to notify physician if unable to obtain lab specimen or of any abnormal findings.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.