Inspection·April 7, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on interview and record review, the facility failed to ensure residents were free from physical abuse (R1) by another resident (R2). This failure affects two resident (R1,R2)) of four reviewed for abuse in the sample of four. Findings include: The facility Abuse Prohibition policy (3/15/2018) documents: All residents have the right to be free of (sic) from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. R1's Medical Diagnosis list (4/6/2023) documents R1's diagnoses include: Hemiplegia and Hemiparesis (paralysis of one side of the body), Cerebral Infarction (stroke), Muscle Weakness, Unsteadiness on Feet, Parkinson's Disease (neurodegenerative disorder), Mild Cognitive Impairment, Depression, and Anxiety Disorder. R1's Minimum Data Set (1/12/2023) documents R1 has moderately impaired cognition. The facility abuse investigation file (3/31/2023) documents V4 (Dietary Manager) overheard R1 yelling help from R1's room. V4 then entered R1's room and found R2 near R1's bed, and R1 reported R2 had thrown R1's clothing onto the floor, knocked over R1's walker, then struck R1 in the shoulder. The same record documents V5 (Certified Nurse Aide) was also present with V4, and removed R2 from R1's room following the incident between R1 and R2. On 4/7/2023 at 10:50AM, V5 reported R2 had thrown R1's walker into the hallway twice before the altercation with R1 on 3/31/2023. V5 also reported taking R2 to the nurse station two times before hearing R1 yell for help from R1's room, and then finding R2 had re-entered R1's room and began throwing R1's items on the ground before hitting R1. V5 reported R1 was just shocked after being hit by R2 and V5 reported removing R2 from R1's room a third time after the incident. On 4/7/2023 at 10:30AM, R1 reported R2 had struck R1 on the shoulder with a closed fist on 3/31/2023. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145546 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MT Zion Health & Rehab Center 1225 Woodland Drive Mount Zion, IL 62549 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)