Mt Zion Health & Rehab Center
1225 Woodland Drive · Mount Zion, IL · 62549 · 2178642356
71 certified beds For profit - Limited Liability company Chain: Summit Healthcare Consulting
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- 3 citations involved actual harm to residents.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.13 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.37 | 0.55–0.75 |
| Weekend hours / resident-day | 2.79 | ≈ weekday level |
| Nursing turnover / year | 53% | median 45% |
| Fines (3-yr window) | 1 · $47,700 |
Inspection citations (51 in the current record)
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Actual harm · G April 28, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 13, 2026 · Quality of Life and Care
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Potential for harm · D April 9, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected April 14, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G December 16, 2025 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected December 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 16, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 17, 2025 · Resident Rights
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Potential for harm · D December 16, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 16, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected December 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 16, 2025 · found via complaint
Provide care by qualified persons according to each resident's written plan of care.
Corrected December 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · E December 16, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 17, 2025 · Quality of Life and Care
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Potential for harm · E December 16, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 17, 2025 · Pharmacy Service
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Actual harm · G October 14, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 15, 2025 · Quality of Life and Care
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Potential for harm · D October 14, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected October 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 18, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 6, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 28, 2024 · Quality of Life and Care
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Potential for harm · D May 2, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 7, 2024 · Quality of Life and Care
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Potential for harm · D February 9, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected February 21, 2024 · Resident Rights
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Potential for harm · D February 9, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected February 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D February 9, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 21, 2024 · Quality of Life and Care
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Potential for harm · D February 9, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected February 21, 2024 · Quality of Life and Care
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Potential for harm · E February 9, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected February 21, 2024 · Pharmacy Service
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Potential for harm · E February 9, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected February 21, 2024 · Pharmacy Service
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Potential for harm · F February 9, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected February 21, 2024 · Pharmacy Service
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Potential for harm · F February 9, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected February 21, 2024 · Nutrition and Dietary
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Potential for harm · F February 9, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected February 21, 2024 · Infection Control
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Potential for harm · D June 12, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 23, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 12, 2023 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected June 23, 2023 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 16, 2025 | Fine | $47,700 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145546 · certified since September 6, 1985. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.