A list of the most recent deficiencies for Mt Zion Health and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-08 | 2024-02-23 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2024-02-08 | 2024-02-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-09 | 2024-02-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-02-09 | 2024-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-02-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-09 | 2024-02-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-09 | 2024-02-21 | N |
| 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. | Health | 2024-02-09 | 2024-02-21 | N |
| 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. | Health | 2024-02-09 | 2024-02-21 | N |
| 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. | Health | 2024-02-09 | 2024-02-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-08 | 2024-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-02-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-12 | 2023-06-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-12 | 2023-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-20 | 2023-05-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-07 | 2023-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-07 | 2023-04-21 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-07 | 2023-04-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-07 | 2023-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-06 | 2022-12-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-06 | 2022-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-19 | 2022-12-30 | N |
| 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. | Health | 2022-12-06 | 2022-12-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-06 | 2022-12-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-12-06 | 2022-12-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-06 | 2022-12-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-06 | 2022-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-06 | 2022-12-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-06 | 2022-12-26 | N |
| 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. | Health | 2022-12-06 | 2022-12-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-06 | 2022-12-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-06 | 2022-12-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-19 | 2022-12-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-19 | 2022-12-23 | N |
| 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. | Health | 2022-12-06 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-06 | 2022-12-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-06 | 2022-12-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-06 | 2022-12-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-04 | 2022-10-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-22 | 2022-10-07 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-22 | 2022-10-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-12 | 2022-08-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-07 | 2022-07-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-07 | 2022-07-23 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-05-12 | 2022-06-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-12 | 2022-06-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-12 | 2022-06-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-26 | 2022-06-13 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-27 | 2022-05-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-04-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-18 | 2022-02-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2021-12-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-02 | 2021-12-17 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-11-08 | 2021-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-08 | 2021-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-08 | 2021-11-18 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-25 | 2021-11-12 | Y |
| Keep all essential equipment working safely. | Health | 2021-10-25 | 2021-11-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-26 | 2021-11-12 | N |
| 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. | Health | 2021-10-26 | 2021-11-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-26 | 2021-11-12 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-26 | 2021-11-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-26 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-26 | 2021-11-12 | N |
| Post nurse staffing information every day. | Health | 2021-10-26 | 2021-11-12 | N |
| 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. | Health | 2021-10-26 | 2021-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-26 | 2021-11-12 | N |
| Keep all essential equipment working safely. | Health | 2021-10-26 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-08-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-16 | 2021-07-01 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-06-16 | 2021-07-01 | Y |
