Mt Zion Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Mt Zion Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF678Oct 25, 2021

  Based on interview and record review, the facility failed to provide emergency medical equipment, airway management, and rescue breathing for R1 during a respiratory medical emergency for one of three residents (R1) reviewed for basic life support. These failures have the potential to affect ten (10) additional residents (R4-R13) who have chosen to be a Full Code. R1 subsequently died of Acute Cardiopulmonary Arrest. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity level two. […]

• Immediate jeopardy, patternF908Oct 25, 2021

  Based on interview and record review, the facility failed to provide and properly maintain essential lifesaving medical equipment during a respiratory medical emergency for R1. R1 did not have the benefit of essential lifesaving equipment including an oral suctioning device and mechanical ventilation device for responding medical staff to use during a respiratory medical crisis. As a result, R1 was not provided airway management and rescue breathing. R1 subsequently died of Acute Cardiopulmonary Arrest. R1 is one of three residents (R1) reviewed for basic life support. This failure has the potential to affect ten (10) additional residents (R4-R13) who have chosen to be a Full Code. […]

• Immediate jeopardy, isolatedF686May 12, 2022

  Based on record review and interview, the facility failed to implement interventions to prevent the development of pressure wounds and to promote healing of facility acquired pressure wounds, failed to develop and implement a plan including pressure relieving interventions to prevent further skin injury, and failed to follow physician orders to implement nutritional supplements for wound healing for one (R2) resident of three residents reviewed for pressure wounds on the sample list of 10 residents. These failures resulted in R2 developing an unstageable deep tissue Injury to the left heel, a stage four pressure wound to the sacrum, and a stage three pressure wound to the right buttock. […]

• Actual harm, isolatedF689Apr 28, 2026

  Based on observation, interviews, and record review, the facility failed to ensure appropriate supervision for a resident identified as a high fall risk and failed to implement care-planned fall interventions for one of three (R5) residents reviewed for accidents from a sample of five. This failure resulted in R5 sustaining a fall that resulted in a displaced fracture in the upper portion of R5's right leg. Findings:The facility's Fall Prevention Program/Protocol, dated 7/01/2023, documented that the purpose of the policy is to provide guidance to facility staff regarding the prevention and reduction of falls within the facility. […]

• Actual harm, isolatedF602Dec 16, 2025

  Based on observations, interview and record review the facility failed to ensure resident right to be free from staff to resident (R1) misappropriation of a credit card. R1 is one of three residents reviewed for abuse/misappropriation on the sample list 31. R1 experienced psychosocial harm, including emotional distress and tearfulness, as a direct result of the misappropriation of her credit card.Findings include:R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) score of 15 out of a possible 15, indicating R1 has no cognitive impairment.R1's Local Police Report, dated 11/24/25, documents that V6, Certified Nursing Assistant (CNA), was arrested by the local police department after using R1's credit card for purchases totaling $1,350.01, as… […]