Mt Zion Health & Rehab Center

Penalties

• Dec 16, 2025 — Fine ($47,700)
• Oct 25, 2023 — IDPH fine (Nursing Home Care Act) ($500)
• Oct 25, 2023 — IDPH fine (Nursing Home Care Act) ($500)
• Oct 25, 2023 — IDPH fine (Nursing Home Care Act) ($1,100)
• Oct 25, 2023 — IDPH fine (Nursing Home Care Act) ($1,100)

Inspection findings

1. May 28, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 12, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0770 Administration Deficiencies

     Provide timely, quality laboratory services/tests to meet the needs of residents.

     Corrected Jun 12, 2026 · CMS health inspection

2. Apr 28, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 12, 2026 · CMS health inspection

3. Apr 9, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Apr 14, 2026 · CMS health inspection

4. Jan 7, 2026 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Mar 9, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 23, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 6, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Mar 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 30, 2026 · CMS fire safety

5. Dec 16, 2025 Health · 7 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 17, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Dec 17, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 17, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 17, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0659 Resident Assessment and Care Planning Deficiencies

     Provide care by qualified persons according to each resident's written plan of care.

     Corrected Dec 17, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 17, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Dec 17, 2025 · CMS health inspection

6. Oct 14, 2025 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 15, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Oct 15, 2025 · CMS health inspection

7. Apr 18, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected May 2, 2025 · CMS health inspection

8. Jun 6, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 28, 2024 · CMS health inspection

9. May 2, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 7, 2024 · CMS health inspection

10. Feb 9, 2024 Fire Safety · 16 findings
    • Not serious Scope/severity F

      E0037 Emergency Preparedness Deficiencies

      Establish staff and initial training requirements.

      Corrected Feb 23, 2024 · CMS fire safety

    • Not serious Scope/severity D

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0661 Resident Assessment and Care Planning Deficiencies

      Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

      Corrected Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0690 Quality of Life and Care Deficiencies

      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 Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0756 Pharmacy Service Deficiencies

      Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

      Corrected Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0758 Pharmacy Service Deficiencies

      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 Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0761 Pharmacy Service Deficiencies

      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 Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0801 Nutrition and Dietary Deficiencies

      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 Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity F Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Feb 21, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Feb 21, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Feb 23, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0711 Miscellaneous Deficiencies

      Provide a written emergency evacuation plan.

      Corrected Feb 23, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Feb 23, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Feb 19, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0930 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure proper storage of liquid oxygen.

      Corrected Feb 23, 2024 · CMS fire safety

11. Oct 25, 2023 IDPH docket NH 23-S1037 · 6 findings
    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.3120g).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.2930c)5).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.610a) and 300.1210d)2). No Fine

      Statement of deficiencies (PDF)

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.330 and 300.2010a)1). No Fine

      Statement of deficiencies (PDF)

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.686b)3). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.668.

      Statement of deficiencies (PDF)

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.661. The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.661.

      Statement of deficiencies (PDF)

12. Dec 6, 2022 Fire Safety · 19 findings
    • Not serious Scope/severity F

      E0039 Emergency Preparedness Deficiencies

      Conduct testing and exercise requirements.

      Corrected Dec 23, 2022 · CMS fire safety

    • Not serious Scope/severity C

      F0575 Resident Rights Deficiencies

      Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

      Corrected Dec 23, 2022 · CMS health inspection

    • Not serious Scope/severity C

      F0577 Resident Rights Deficiencies

      Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

      Corrected Dec 23, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0580 Resident Rights Deficiencies

      Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

      Corrected Dec 23, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Dec 6, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Dec 31, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0727 Nursing and Physician Services Deficiencies

      Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

      Corrected Dec 16, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Dec 6, 2022 · CMS health inspection

    • Not serious Scope/severity E

      F0758 Pharmacy Service Deficiencies

      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 Dec 28, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Dec 16, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity F

      F0882 Infection Control Deficiencies

      Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

      Corrected Dec 26, 2022 · CMS health inspection

    • Not serious Scope/severity D

      F0883 Infection Control Deficiencies

      Develop and implement policies and procedures for flu and pneumonia vaccinations.

      Corrected Dec 31, 2022 · CMS health inspection

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Dec 23, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0354 Smoke Deficiencies

      Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

      Corrected Dec 30, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• CLARK, LACY — w-2 managing employee, NOT APPLICABLE, since 07/01/2023
• LICHTMAN, SHALOM — corporate officer, NOT APPLICABLE, since 07/01/2023
• LICHTMAN, SHALOM — operational/managerial control, NOT APPLICABLE, since 07/01/2023
• APOGEE TR — 5% or greater indirect ownership interest, since 07/01/2023
• LIGHT MAN LLC — operational/managerial control, NOT APPLICABLE, since 07/01/2023
• SC ILLINOIS HOLDCO LLC — 5% or greater direct ownership interest, 100%, since 07/01/2023
• SC ILLINOIS I TBD HOLDCO LLC — 5% or greater indirect ownership interest, since 07/01/2023