Health 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. Page 1 of 4 145546 145546 04/07/2023 MT Zion Health & Rehab Center 1225 Woodland Drive Mount Zion, IL 62549

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to thoroughly investigate and document an allegation of resident-to-resident physical abuse. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four. Residents Affected - Few Findings include: The facility Abuse Prohibition policy (3/15/2018) documents after the facility receives an allegation of abuse, the facility Administrator or designee shall investigate all alleged instances of abuse and the investigation shall include, if possible, interviews with all involved parties and potential witnesses, and signed statements from anyone who saw or heard information pertinent to the incident. 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 placed 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. The facility abuse investigation file does not document V5's observations of R1's walker being in the hallway twice, or V5's removal of R2 from R1's room twice before R2 struck R1 in the shoulder followed by V5 removing R2 from R1's room a third time. On 4/7/2023 at 1:30PM, V1 (Administrator) reported the 3/31/23 facility abuse investigation file was the complete investigation for the incident between R1 and R2. On 4/6/2023, the above facility abuse investigation failed to document any potential resident witnesses to the altercation between R1 and R2, and failed to obtain any staff statements related to the incident other than from V5. The same record failed to document any subsequent monitoring or assessment of potential resident psychosocial outcomes following R2's physical abuse or R1 on 3/31/2023. On 4/7/2023 at 1:30PM, V1 reported the facility abuse investigation concluded R2 did hit R1 on 3/31/2023. V1 denied interviewing any other residents to determine if R2 was involved with any additional instances of abuse towards other residents. 145546 Page 2 of 4 145546 04/07/2023 MT Zion Health & Rehab Center 1225 Woodland Drive Mount Zion, IL 62549

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and record review, the facility failed to update and revise a resident care plan following an incident of resident-to-resident physical abuse. This failure affects one resident (R1) of four reviewed for abuse in the sample of four. Findings include: 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. On 4/7/2023 at 1:30PM, V1 reported the facility abuse investigation concluded R2 did hit R1 on 3/31/2023. On 4/7/2023 at 10:30AM, R1 reported R2 had struck R1 on the shoulder with a closed fist on 3/31/2023. On 4/7/2023 at 1:30PM, V1 (Administrator) was unsure if the facility completed any abuse risk assessments for either R1 or R2. R1's Care Plan (4/6/2023) does not document any care planning related to R2's physical abuse of R1 occurring on 3/31/2023. 145546 Page 3 of 4 145546 04/07/2023 MT Zion Health & Rehab Center 1225 Woodland Drive Mount Zion, IL 62549

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to fully document the details of a resident-to-resident physical abuse allegation and investigation in residents' medical records. This failure affects two residents (R1, R2) of four reviewed for abuse in the sample of four. Findings include: 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. On 4/7/2023 at 1:30PM, V1 (Administrator) reported the facility abuse investigation concluded R2 did hit R1 on 3/31/2023. On 4/7/2023 at 10:30AM, R1 reported R2 had struck R1 on the shoulder with a closed fist on 3/31/2023. R1's electronic medical record (undated) and nursing progress notes (3/31/2023-present) did not document the above incident and did not document who reported the physical abuse allegation to V1, when the allegation was reported, the specific nature of the allegation, any witnesses to the altercation, immediate actions facility staff undertook to prevent the potential for further abuse, or resident outcomes of the abuse or facility investigation. R2's electronic medical record (undated) and nursing progress notes (3/31/2023-present) did not document who reported the physical abuse allegation to V1, when the allegation was reported, the specific nature of the allegation, any witnesses to the altercation, of immediate actions facility staff undertook to prevent the potential for further abuse, or resident outcomes of the abuse or facility investigation. On 4/7/2023 at 1:30PM, V1 reported the 3/31/23 facility investigation file was the complete investigation for the incident. V1 also reported R1 and R2's medical records did not document who reported the allegation, when it was reported, the nature of the 3/31/2023 incident between R1 and R2, any potential witnesses to the altercation, or the immediate actions the facility took to prevent the potential for further resident abuse. 145546 Page 4 of 4