Inspection·June 12, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's Nurse Progress Note, dated 6/8/23 at 2:11 PM, documents, (R1) observed sitting in hallway in wheelchair. (R2) complained of (R1) running over (R2's) toes. (R2) holding Left side of face with glasses in hand. (R2) states (R1) slapped (R2) and ran over her toes. On 6/11/23 at 1:00 PM, V5, Licensed Practical Nurse (LPN), stated, I was sitting at the nurses desk doing some paperwork. (R2) was sitting in her wheelchair on the opposite side of nurses desk. I couldn't see (R2) since I was sitting down, but I did see (R1) wheeling herself up the hall. A minute later, I heard a slap sound. I got up from the nurses desk to see (R1) wheeling away from (R2), and (R2) was sitting with her mouth open and holding her glasses in her hands. (R2) denied pain. I took (R2) into her room and assessed her skin. (R2) had no redness on her face or feet. On 6/11/23 at 2:15 PM, V2, Director of Nurses, stated, I was trying to figure out how (R2's) right great toe might have gotten that reddened area. I think (R1) was wheeling herself in her wheelchair down the hall and approached (R2) from (R2's) left side. Since (R2) was slapped on the left side of her face, that would make sense. I think (R1) just didn't like (R2) questioning (R1) about running over (R2's) toes. (R1) gets more agitated with any kind of confrontation. On 6/12/23 at 2:00 PM, V1, Administrator, confirmed R1 was self propelling wheelchair in front of R2, when R1 rolled over R2's toes. V1 stated that act caused R2 to say to R1 'do not run over my toes'. V1 stated R1 then became agitated, and slapped R2 across the left cheek. V1 Administrator stated That is the epitome of physical abuse. (R1) should not have slapped (R2) across the face. The facility abuse policy titled 'Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media', revised 3/15/18, documents all residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse means the infliction of injury on a resident that occurs other than by accidental means and that required (whether or not given) medical attention. Physical abuse may include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling and pinching, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 2 of 4 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 06/12/2023 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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse prevention policy by failing to ensure allegations of resident to resident verbal and physical abuse were reported to the administrator for one of six residents (R1) reviewed for abuse on the sample list of six residents. Residents Affected - Few Findings include: The facility abuse policy titled 'Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media', revised 3/15/18, documents all residents have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse means the infliction of injury on a resident that occurs other than by accidental means and that required (whether or not given) medical attention. Physical abuse may include, but is not limited to such acts as: hitting, slapping, kicking, hair pulling and pinching, etc. A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. If the incident involves alleged abuse, neglect or incident of unknown origin, the incident will immediately be reported to the Administrator and the Administrator shall provide the Illinois Department of Public Health with initial notice of the alleged abuse, neglect, or incident of unknown origin by telefaxing to the Department a copy of a report of the incident completed immediately after the incident becomes known. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as moderately cognitively impaired. This same MDS documents R1 as requiring extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene, and supervision for locomotion on and off unit. This same MDS documents R1 uses a wheelchair for mobility. R1's Careplan intervention, dated 1/20/23, documents staff to Offer, encourage, and assist (R1) with ambulation when anxious, restless, or fidgety to help with my anxiety. This same care plan documents an intervention dated 4/4/23 to When agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. R1's Nurse Progress Note, dated 5/28/23 at 3:38 PM, documents, (R1) wandering hallways and entering various residents rooms. (R1) becoming aggressive and holding her fist up at other residents and throwing items. R1's Nurse Progress Note, dated 6/3/23 at 2:58 PM, documents, Behaviors: (R1) very restless and agitated. (R1) noted to roam hallways aimlessly, entering others rooms and becoming aggressive, waving her fist at other residents for no apparent reason. When attempting to redirect resident she becomes very agitated and combative with staff, hitting and scratching. (R1) can be redirected only short periods at a time. R1's Nurse Progress Note ,dated 6/4/23 at 5:04 PM, documents, (R1) becoming verbally aggressive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 3 of 4 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 06/12/2023 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)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with other resident for no apparent reason. Noted to become physically aggressive with staff when attempting to redirect (R1). Continuous throughout the day with restlessness. Noted to exit seek at times. (R1) Banging and hitting on doors. (R1) noted to slam a neighboring residents door when staff attempting to remove her from their room. (R1) roaming aimlessly in hallways. R1's Nurse Progress Note, dated 6/6/23 at 8:01 AM, documents, (R1) has off and on episodes of aggressive behaviors all day. Redirection at times accepted by (R1) and other time approaching her (R1)threatened and becomes more upset. Episodes have became more frequent and more aggressive. Nothing appears to prompt the behaviors, it just happens. On 6/12/23 at 2:05 PM, V1, Administrator, stated ,Any allegation, witnessing or suspicion of abuse should always be reported to the Administrator/Abuse Coordinator. The documentation for (R1) as being verbally and physically aggressive with other residents should have been reported. That way, the Administrator could have started interviewing, found out who the other residents were, if there were any effects on the other residents, and began the investigation and reporting process. Since the staff did not report those events to me or anyone else, the Abuse policy was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 4 of 4