Mount Zion, IL
1-star overall rating with 2-star inspections with abuse icon flag with 19 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1225 Woodland Drive, Mount Zion, IL
(217) 864-2356
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
71
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Summit Healthcare Consulting
Operator or chain grouping
Approved since
1985-09-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 4 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.47
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
2.72
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
10,560
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.74% · Performance 21.56% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.30
Baseline 7.92% · Performance 6.85% · Measure score 3.30 · Achievement 3.30 · Improvement 3.17
Total nurse turnover
4.68
Baseline 71.05% · Performance 47.14% · Measure score 4.68 · Achievement 4.05 · Improvement 4.68
Adjusted total nurse staffing
0
Baseline 3.67 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 9.38% · Lower 95% interval 7.15% |
| Discharge to community | 42.61% |
50.57%
8 pts worse
|
No Different than the National Rate · Eligible stays 81 · Observed rate 34.57% · Lower 95% interval 33.2% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 90 · Denominator 90 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 90 |
| Discharge self-care score | 7.41% |
53.69%
46.3 pts worse
|
Numerator 4 · Denominator 54 |
| Discharge mobility score | 7.41% |
50.94%
43.5 pts worse
|
Numerator 4 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 90 · Adjusted rate 1.8% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 6.82% · Lower 95% interval 4.14% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 60.53% |
42%
18.5 pts better
|
Numerator 46 · Denominator 76 |
| Discharge function score | 12.96% |
56.45%
43.5 pts worse
|
Numerator 7 · Denominator 54 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 31 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 2 · Denominator 40 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.6%
10 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.2% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
91.6%
3.7 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 5.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 31.1% |
50.3%
19.2 pts better
|
11.4%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.4% · Q3 25.5% · Q4 89.1% · 4Q avg 31.1% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.5%
1.6 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.1% · Q3 12.2% · Q4 12.2% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
18.5%
7.4 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 25.5% · Q3 24.0% · Q4 26.9% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
22.8%
3.7 pts better
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 17.1% · Q3 16.2% · Q4 20.0% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
17.2%
0.6 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
15.0%
11 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 5.9% · Q3 0.0% · Q4 1.9% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
21.3%
6.3 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 23.0% · Q3 29.6% · Q4 26.4% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.2%
1.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.8% · Q3 7.8% · Q4 11.3% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
68.8%
30.8 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
14.0%
2.7 pts better
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 10.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
2.3%
About the same
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.0% · Q3 0.0% · Q4 3.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
63.0%
17.4 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
26.2%
1.7 pts better
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 23.5% · Expected 22.8% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-23
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-21
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2024-02-23
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-23
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-12-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-11-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-18
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-18
Inspection history
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-17
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-17
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-17
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-17
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2025-12-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-10-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-07
Health
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 2024-02-21
Health
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 2024-02-21
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-21
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-21
Health
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 2024-02-21
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-21
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-02-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-21
Health
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 2024-02-21
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-23
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-23
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-21
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-21
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-21
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-21
Health
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 2022-12-16
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-16
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-26
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-12-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-12-23
Health
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 2022-12-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-12-06
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-12-26
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-12-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-31
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-31
Health
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 2022-12-23
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-12-23
Health
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 2021-11-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-12
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2021-11-12
Health
Keep all essential equipment working safely.
Corrected 2021-11-12
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-11-12
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-11-12
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-12
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2021-11-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-11-12
Health
Post nurse staffing information every day.
Corrected 2021-11-12
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Decatur, IL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $83,223 in total fines with 32 recent health deficiencies
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