Inspection·February 9, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary/recapitulation of stay for one (R64) resident out of one resident reviewed for discharge in a sample list of 28 residents. Findings include: R64's undated Face Sheet documents R64 admitted to the facility on [DATE], and discharged to an Assisted Living Facility on 11/13/23. This same Face Sheet documents medical diagnoses of Pneumonia due to other Bacteria, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Hypertension. R64's Physician Order Sheet (POS), dated November 2023, documents a physician order, dated 11/13/23, of OK to discharge to assisted living with current orders. R64's Minimum Data Set (MDS), dated [DATE], documents R64 was moderately cognitively impaired. R64's Nurse Progress note, dated 11/13/23 at 2:59 PM, documents, (R64) discharged to Assisted Living Facility to start hospice services. Transportation was provided by family. Vitals are stable. No complaints of pain. Report given to facility. R64's Electronic Medical Record (EMR) does not document a recapitulation of stay progress note or discharge summary assessment. On 2/9/24 at 8:35 AM, V1, Administrator, stated R64 admitted to the facility intending to be a short term resident. V1 stated R64 had previously stayed at the same Assisted Living Center and had a decline in condition. V1 stated R64's family thought R64 would improve by being at this facility but quickly changed their mind and discharged (R64) back to the assisted living center to start hospice. V1 confirmed the facility did not complete a recapitulation of stay or discharge summary assessment. The facility policy titled 'Discharge/Transfer Policy', dated 7/2/2023, documents when the facility transfers or discharges residents under any circumstances appropriate documentation will be made in the resident's clinical record. If a resident is to be transferred or discharged to another health care facility upon order of the Physician, a transfer/discharge assessment will be completed in the Electronic Medical Record (EMR). A copy is sent with the resident, a copy is mailed to the responsible party and a copy is filed in the resident record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 2 of 16 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 02/09/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to implement post-fall nursing interventions according to a resident's care plan for fall prevention. This failure affects one resident (R26) out of five reviewed for accidents on the sample list of 28. Findings include: R26's Care Plan for fall prevention, dated initiated 4/11/16, documents, I am at risk for falls r/t (related to) unaware of safety needs, Confusion, Psychoactive drug use, Gait/balance problems. I will often transfer myself even though I know I am not supposed to. The nursing intervention documented, initiated 12/28/23, documents floor mat added next to the bed for safety. R26's Fall Risk Assessments, dated 1/27/24, 1/18/24, 12/8/23, and 10/2/23, all document R26 as a high risk for falls with scores of 19, 19, 17, and 15, respectively, with 10 and higher being rated as high risk. R26's Nursing Progress Notes, dated 1/27/2024, document, CNA (Certified Nursing Assistant) alerted this writer that resident was on the floor. When arrived to resident's room, found resident lying on the floor between w/c (wheelchair) and bed. CNA states that w/c was next to bed, and she turned her back to get something out of resident's closet, and behind her heard a noise, and turned around and saw that resident had self-transferred from w/c to bed, but was not securely sitting on the bed. CNA then lowered resident to floor, and alerted this nurse. R26's Nursing Progress Notes, dated 1/6/2024, document, Resident noted on floor laying on her left side next to bed. Resident attempted to transfer herself to bed. Skin tear noted to right forearm. Wound cleaned, skin approximated, and (adhesive strips) applied. ROM (range of motion) completed with no c/o (complaint of) pain. R26's Nursing Progress Note, dated 2/2/2024, documents, Resident continues with (company) hospice. Takes medications crushed, incontinent of bowel and bladder, needs extensive assistance with ADL's (Activities of Daily Living), and is two assist with (full body mechanical) lift. Resident is currently resting comfortably in no apparent distress noted. Due to high risk for falls has bed/chair alarm in place for safety, and d/t (due to) impaired judgement resident known to self-transfer from w/c (wheelchair) to bed w/o (without) staff assistance, this behavior has resulted in resident's history of falls, and she continues to remain a high-risk for falls. On 2/7/24 at 1:21 PM, there was not a floor mat next to R26's bed. There was a floor mat folded and standing upright next to R26's recliner, in plain sight approximately 7 feet away from R26's bed. V10, Licensed Practical Nurse, stated, (R26) was up for lunch and she just got laid down about 2 minutes ago. On 2/9/24 at 9:28 AM, V5, Care Plan Coordinator, stated, (R26's) floor mat was initiated 12/28/23 and it is a current intervention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 3 of 16 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 02/09/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change the urinary catheter every 28 days for one resident (R315) out of two residents reviewed for urinary catheters in a sample list of 28 residents. Findings Include: 1. R315's undated Face Sheet documents an admission date of 1/9/24. This same Face Sheet documents R315's medical diagnoses of Urinary Tract Infection, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Type 2 Diabetes Mellitus Without Complications, Bladder-Neck Obstruction, Obstructive And Reflux Uropathy, Hydronephrosis With Renal And Ureteral Calculous Obstruction. R315's Minimum Data Set (MDS), dated [DATE], documents R315 as cognitively moderately impaired. This same MDS documents R315 as requiring maximum one person assist for toileting, bathing, and catheter/perineal care. R315's Physician Order Sheet (POS), dated January 2024, documents a physician order starting 1/09/24 to change the urinary catheter every 28 days. On 2/7/24 at 11:00 AM, R315's urinary catheter drainage bag was attached to the underside of the wheelchair in a dignity bag. R315 stated he is unable to recall if his (R315's) urinary catheter was changed the night of 2/6/24. On 2/7/24 at 10:52 AM, V2, Director of Nursing (DON), stated, The Treatment Administration Record is not signed by the nurse indicating the task was not completed. V2 stated there is no progress note in the medical record indicating the urinary catheter was changed every 28 days as ordered by the physician. The Catheter Insertion/Maintenance Policy and Procedure, dated 07/01/23, documents the procedure (changing of urinary catheter) will be documented in the residents medical record by staff when completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 4 of 16 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 02/09/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to obtain Physician responses to Registered Pharmacist recommendations, failed to implement physician responses, and failed to maintain records of medication regimen review reports. This failure affects three residents (R14, R31, and R48) out of five reviewed for unnecessary medications on the sample list of 28. Findings include: 1. R31's Pharmacy Medication Regimen Review (MRR), dated 9/14/23, documents a Registered Pharmacist (V20) recommendation, This resident started the anti-psychotic Prochlorperazine 10 milligrams (mg) every 6 hours as needed (PRN) on 7/23/23. This medication has never been used. According to regulatory guidelines, anti-psychotic medications on a PRN basis must be limited to 14 days. R31's Physician (V9) responded to the recommendation to discontinue the medication Prochlorperazine, signed and dated this order 10/6/23. R31's historical Physician Order Sheet, dated (printed) 2/8/24, documents the medication Prochlorperazine was not discontinued by the facility until 11/28/23. R31's Medication Administration Report (MAR) dated for October 2023 documents R31 was administered the medication Prochlorperazine one time on 10/18/23, after the physician had ordered to discontinue. 2. R31's MRR, dated 12/18/23, documents, See report for any noted irregularities or recommendations. On 2/8/24 at 10:22 AM, V2, Director of Nursing, reviewed R31's 12/18/23 MRR and noted the documented status that a report had been made with noted irregularities or recommendations by the Registered Pharmacist (V20). V2 stated, What the pharmacy sent me is what I gave you (9/14/23 report), but this all happened before I worked here. I have been here about a month and I have a lot of ideas to integrate these separate systems, so if you come back next year things will be better. 3. R14's MRR, dated 10/20/23, documents a recommendation from the Registered Pharmacist to check R14's Vitamin B-12 level now and annually, due to receiving the diabetic medication Metformin. There was not a documented physician response from this MRR recommendation. On 2/8/24 at 1:35 PM, V2, Director of Nursing, stated, I just faxed this to the doctor (V9) today and waiting to see what he wants to do. R14's Laboratory Report, dated 12/20/23, documents R14 did not have a B-12 level checked until this date, 2 months after the recommendation. 4. R14's MRR, dated 12/18/23, documents a recommendation from the Registered Pharmacist (V20), This resident receives the following medication for Depression, Zoloft 100 mg every morning. This resident continues also on Seroquel (anti-psychotic) 25 mg every bedtime and has had multiple reported falls. CMS (Centers for Medicare and Medicaid Services) requires attempts at dose reductions on medications taken for depression. The Pharmacist provided options for the physician to mark The continued use is in accordance with accepted standards, or The resident's targeted symptoms worsened after the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 5 of 16 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 02/09/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm most recent dose reduction, or Accept the Pharmacist recommendation for dose reduction from Zoloft 100 mg every morning, to Zoloft 100 mg in the morning Monday Through Friday and Zoloft 75 mg Saturday and Sunday. This MRR, dated 12/18/23, does not document any physician response. Residents Affected - Some On 2/8/24 at 1:35 PM, V2, Director of Nursing, stated, That is the same thing I said, I just faxed this to the doctor today and am waiting to see what he wants to do. 5. R48's MRR, dated 9/15/23, documents a Registered Pharmacist (V20) recommendation, This resident has an order for the medication Pantoprazole 40 mg twice daily since 3/17/23. The recommended duration of therapy with this medication is 4 - 6 weeks due to an increased risk of gastro-intestinal infections, pneumonia, osteoporosis, and B-12 deficiency. R14's Physician (V9) marked the selection to discontinue the medication Pantoprazole and start the new medication Famotidine (Pepcid) 10 mg twice daily, ordered, signed and dated 10/6/23. R48's current Physician Order Sheet (2/8/24) documents R48 continues to have a physician order for Pantoprazole 40 mg twice daily. R48's historical Physician Order Sheet documents R48 has never had the order for Famotidine (Pepcid) recorded into the physician orders nor implemented. 6. R48's MRR, dated 9/15/23, documents a Registered Pharmacist recommendation to check R48's laboratory levels of glycosylated hemoglobin at the next lab draw and every 4 months, comprehensive metabolic panel at the next lab draw and every 6 months, vitamin D at the next lab draw and annually, and lipids at the next lab draw and annually. R48's Physician (V9) accepted the recommendations, signed and dated as orders on 10/6/23. R48's MRR, dated 10/24/23, documents the same Registered Pharmacist (V20) recommendation for the same laboratory levels to be checked as recommended on 9/15/23 as the laboratory level checks were not documented in R48's medical record. There was no documented physician response to this MRR recommendations. R48's Laboratory Report, dated 11/15/23, documents R48 did not have these lab values and levels checked until 11/15/23. On 2/9/23 at 12:07 PM, V2, Director of Nursing, stated, Our lab comes here every Monday, Wednesday, and Friday. 7. R48's MRR, dated 12/18/23, documents a Registered Pharmacist (V20) recommendation, This resident receives the anti-psychotic medication Seroquel (Quetiapine) added 12/5/23. This medication is associated with Extrapyramidal side effects (abnormal involuntary movements). Please consider performing an AIMS (abnormal involuntary movement scale) assessment every 6 months and with any dosage increases while this resident receives this anti-psychotic medication. R48's current Physician Order Sheets (printed 2/8/24) confirm R48 has taken the anti-psychotic medication Quetiapine since 12/5/24. R48's AIMS (Abnormal Involuntary Movement Scale) assessment was dated 1/30/24, nearly 2 months after R48 began taking the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 6 of 16 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 02/09/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm The facility's policy Psychotropic Medications Protocol Chemical Restraints, dated 9/15/19, documents, All residents who receive anti-psychotic medications will have an AIMS assessment completed every 6 months and as needed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 7 of 16 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 02/09/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete initial and quarterly psychotropic medication assessments, psychotropic Abnormal Involuntary Movement Scale (AIMS), and psychotropic gradual dose reductions for six of seven residents (R8, R27, R29, R31, R48, R168) reviewed for psychotropic medications on the sample list of 28. Findings Include: 1. R29's Medical Diagnoses List, dated February 2024, documents R29 is diagnosed with Dementia, Anxiety, and Major Depression. R29's Physician Order Sheet, dated February 2024, documents orders for Trazodone (Sedative) 50 milligrams at bedtime for Major Depression, Sertraline (Anti-depressant) 25 milligrams daily for Major Depression, and Lorazepam (Anti-anxiety) 0.5 milligrams daily for Anxiety. R29's Medical Record had no record of any Psychotropic Medication Assessments completed for these medications since March 2023. 2. R168's Medical Diagnoses List, dated February 2024, documents R168 is diagnosed with Dementia with Behavioral Disturbance, Adjustment Disorder with Mixed Anxiety and Depressed Mood, Anxiety, Depression, and Post Traumatic Stress Disorder. R168's Physician Order Sheet dated February 2024 documents orders for Olanzapine (Anti-Psychotic) 2.5 milligrams at bedtime every other day for Adjustment Disorder with Mixed Anxiety and Depressed Mood and Sertraline (Anti-depressant) 25 milligrams daily for Depression. R168's Medical Record had no record of any Psychotropic Medication Assessments completed for R168's Sertraline medication. On 2/8/24 at 1:30 PM, V2, Director of Nurses, confirmed both R29 and R168 should have had Psychotropic Medication Assessments completed and did not. 3. R31's current Physician Order Sheet, dated 2/8/24, documents R48 has taken psychotropic medications including Alprazolam (anti-anxiety) since 12/19/22, Sertraline (anti-depressant) since 12/20/22, and Seroquel (anti-psychotic) since 6/24/23. R31's Electronic Medical Record as of 2/8/24, did not include any psychotropic medication assessments to determine targeted behaviors and decline or improvement in these behaviors. The facility's policy Psychotropic Medications Protocol Chemical Restraints, dated 9/15/19, documents, Each resident taking psychoactive medications shall have their medications reviewed and documented by a physician 2 times a year, monthly by the Pharmacy Consultant, and quarterly or as needed by the interdisciplinary Team. 4. R48's current Physician Order Sheets, dated 2/8/24, document R48 has taken the anti-psychotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 8 of 16 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 02/09/2024 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 0758 medication Quetiapine (Seroquel) since 12/5/24. Level of Harm - Minimal harm or potential for actual harm R48's AIMS assessment was dated 1/30/24, nearly 2 months after R48 began taking the medication. Residents Affected - Some The facility's policy Psychotropic Medications Protocol Chemical Restraints, dated 9/15/19, documents, All residents who receive anti-psychotic medications will have an AIMS assessment completed every 6 months and as needed. 5. R27's Minimum Data Set (MDS), dated [DATE], documents R27 as cognitively intact. R27's Care plan intervention, dated 9/27/23, instructs staff to attempt Gradual Dose Reduction (GDR) when appropriate, ensuring lowest strength is utilized when continuing to adequately treat diagnosis. This same care plan documents medical diagnoses of Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder, General Anxiety Disorder, Sleep Disorder and Chronic Pain Syndrome. R27's Physician Order Sheet (POS), dated February 2024, documents physician orders for Celexa (Antidepressant) 40 milligrams (mg) daily starting 9/1/2023 with no end date, Buspirone Hydrochloride (Anti-anxiety) 15 mg twice daily starting 8/31/23 with no end date, Lorazepam 0.5 mg twice daily with no end date and Trazodone 50 mg daily with no end date. R27's POS does not document a dose reduction of R27's Celexa. R27's Note to Attending Physician from Pharmacy, dated 9/15/23, documents R27 takes more than one anti-depressant: Celexa 40 milligrams (mg) daily and Trazodone 50 mg daily. This same note documents Please consider a trial reduction to Celexa 20 mg daily. This same note included a comment section that was hand written Will Gradual Dose Reduction (GDR) Celexa and then look at other medications signed by V9 Physician on 10/6/23. R27's Electronic Medical Record (EMR) does not document Psychotropic Assessments nor Gradual Dose Reductions (GDR) for R27's Psychotropic medications. 6. R8's Minimum Data Set (MDS), dated [DATE], documents R8 as cognitively intact. R8's Care Plan documents R8's medical diagnoses of Anxiety Disorder, Delusional Disorders, Hemiplegia Affecting Left non-dominant side, and Parkinson's Disease. R8's Physician Order Sheet (POS), dated February 2024, documents physician orders for Zoloft 25 milligrams (mg) daily for Major Depressive Disorder starting 7/10/22 with no end date and Xanax 0.25 mg twice per day for Anxiety starting 9/20/22 with no end dated. R8's Electronic Medical Record (EMR) documents Psychotropic Assessments being completed on 7/5/23 for R8's Zoloft and Xanax. This same EMR does not document any further assessments for R8's Psychotropic medications as being completed. On 2/7/24 at 4:00 PM, V2, Director of Nurses (DON), stated the facility has undergone management changes along with new ownership. V2 stated V2 is working on getting all of the programs back in compliance. V2, DON, stated, All Psychotropic medications should have assessments completed with any new order and then quarterly. There is no documentation that the Psychotropic Assessments have been completed. The resident's Electronic Medical Record (EMR) would contain all of the required information. If the EMR does not contain the Gradual Dose Reductions (GDR) or Psychotropic Assessments for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 9 of 16 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 02/09/2024 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 0758 Psychotropic medications, then they just were not done. Level of Harm - Minimal harm or potential for actual harm The facility policy titled 'Psychotropic Medications Policy Chemical Restraints', dated 7/1/2023, documents, In accordance with federal and state regulations, it is the facility's policy that residents will not be given unnecessary medications. Psychotropic/psychoactive medication will not be prescribed without the informed consent of the resident, the resident's guardian or other authorized representative. Residents shall only be given Antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. Residents who receive Antipsychotic/psychoactive medications shall have gradual dose reductions attempted in accordance with state and federal regulation and behavior interventions reviewed, unless clinically contraindicated. Each resident taking Antipsychotic/psychoactive medications shall have their medications reviewed and documented by a physician two times a year, monthly by the Pharmacy Consultant and quarterly or as needed by the Interdisciplinary Team. Residents who use Antipsychotic, Antianxiety, or sedative/hypnotic medication will be reviewed as appropriate for a gradual dose reduction, as per federal and state regulations, unless the physician documents in the medical record the need to maintain the resident's regimen. All residents who receive Antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) assessment completed every six months and as needed. Should the gradual dose reduction cause an adverse effect on the resident, and the gradual dose reduction is discontinued, documentation of the is decision and the reasons for it must be included in the medical record. The care plan will include objectives for gradual dose reduction as well as alternative interventions to assist in gradual dose reduction in accordance with state and federal guidelines. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 10 of 16 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 02/09/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review, the facility failed to ensure the proper storage of medications and biologicals by allowing non-licensed personnel access to nurses medication rooms and not ensuring nurses medication cart was supervised by a licensed nurse. This failure has the potential to affect all 62 residents residing in facility. Findings include: The facility policy titled 'Mediation Storage Policy', dated 7/1/2023, documents the facility drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications may have access to locked medications. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes ) containing drugs and biologicals shall be locked when not in use. Unlocked medications carts are not left unattended. The facility Room Roster, dated 2/6/24, documents 62 residents reside in facility. 1. On 2/7/24 at 8:15 AM, V18, Maintenance Director, exited the locked nurses medication storage room alone. V18, Maintenance Director, handed V17, Licensed Practical Nurse (LPN), the keys to V17's medication cart, which included the keys to the nurses medication storage room. On 2/7/24 at 8:25 AM, V18, Maintenance Director, stated V18 obtains nurses keys to medication rooms on both sides of the facility and checks the temperatures on the refrigerators in the medication rooms every morning. V18 stated, I just go in and check the temperatures and then leave. The nurses give me the keys. I don't bother anything else. I do this everyday. I am responsible for checking the temperatures for all the refrigerators, so that is why I do it. On 2/7/24 at 8:25 AM, V17, Licensed Practical Nurse (LPN), stated, I gave (V18) Maintenance Director the keys to the nurses medication room. (V18) goes in the med room to check the temperature on the refrigerator and then brings me my keys back. I give (V18) my keys every day. I think all the nurses do it. 2. On 2/7/24 at 7:50 AM, a medication cart was sitting in the resident South hallway unattended by the Licensed Nurse and unlocked for five minutes. A laptop computer was sitting on top of the unlocked medication cart with a list of all resident names for residents assigned to V10, Licensed Practical Nurse (LPN). At that time, staff were walking by medication cart assisting other residents in the hallway. V10, LPN, exited a resident room where the door had been closed and V10 walked up to the unlocked medication cart. On 2/7/24 at 7:55 AM, V10, Licensed Practical Nurse (LPN), stated V10's medication cart should have been locked when not in her full view. On 2/7/24 at 12:20 PM, V2, Director of Nurses (DON), stated all medications should be under lock and key. V2, DON, stated the nurses medication carts should always be supervised by a licensed nurse. V2, DON, stated V10, LPN, should have locked the medication cart before walking away and assisting another resident in another room. V2, DON, stated only the licensed nurses should be in possession of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 11 of 16 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 02/09/2024 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 0761 the keys to the medication carts or to the nurses medication rooms. V2, DON, stated V2 will inservice staff to ensure all of the medications are stored properly. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 12 of 16 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 02/09/2024 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review, the facility failed to provide the services of a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 2/6/24 at 9:55 AM, V3, Dietary Manager, was actively managing kitchen personnel and directing the food sanitation and preparation activities in the facility's kitchen. On 2/6/24 at 9:55 AM, V3 stated, I am the Dietary Manager. I have a CFM (Certified Food Manager, sanitation) certificate. This certificate was done online and I answered 120 questions. It took one day. V3's certificate for Certified Food Manager was dated issued 11/1/21, and documented valid for 3 years from that date. On 2/6/24 at 10:00 AM, V3 further stated, I do not have a CDM (Certified Dietary Manager) nor CFPP (Certified Food Protection Manager) certificate. I do have a Food Sanitation (Cook) certificate since 1994. V3 then stated, I do not have any military experience. I started at this facility as Dietary Manager 7/23/21. On 2/7/24 at 2:51 PM, V3 stated her qualifications as related to CMS (Centers for Medicare and Medicaid Services) requirements by stating, I am not an RD (Registered Dietician). We have an RD who works as a consultant. I enrolled in the CDM course in January 2024 through (national university), but I have not yet completed any of the course work modules because they say they have a back order on books. I am a CFM. I also have a 2-year Chef certificate from (local community college). I have been Dietary Manager at other places like assisted living facilities from 1999 until 2018, and Assistant Dietary Manager at another nursing home from 2018 until 2021 when I started here. V3 then confirmed she did not meet the state requirements as a Director of Food Services, or Dietetic Service Supervisor, by stating, I am not a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Clinical Board of Nutrition. I did not graduate from any course prior to 1990, my first job was 1994. I have not completed a CDM course. I do not have a CDM certificate. I don't have any military experience. During the course of the survey, there were infection control issues identified among the kitchen service personnel such as the touching and readjusting of face masks followed by the touching and handling of cups, glasses, lids, and conducting food service, without benefit of any hand hygiene, and reaching in pockets for writing utensils followed by handling cups, glasses, and lids, without benefit of hand hygiene . The facility's Line List for Covid-19 Outbreaks in Long Term Care facilities, dated 1/29/24 through 2/8/24, documents 19 residents tested positive for Covid-19. The facility's current Resident Roster (undated) documents 62 residents reside in the facility, all of whom consume food prepared by the facility's kitchen service personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 13 of 16 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 02/09/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Failures at this level required more than one deficient practice statement. Residents Affected - Many A. Based on observation, interview, and record review, the facility failed to maintain infection prevention procedures to provide a sanitary environment during dietary meal services. This failure has the potential to affect all 62 residents residing in the facility. B. Based on observation, interview, and record review the facility failed to follow a physician order for Contact Isolation Precautions for one (R12) resident of one resident reviewed for infection control in a sample list of 28 residents. Findings Include: A. On 2/6/24 at 9:50 AM, V1, Administrator, stated the facility is in outbreak status for Covid-19. On 2/6/24 at 3:15 PM, V2, Director of Nursing/ Infection Preventionist, confirmed the facility was in outbreak status with residents, and staff, testing positive for Covid-19. The facility's Line List for Covid-19 Outbreaks in Long Term Care facilities, dated 1/29/24 through 2/8/24, documents 19 residents tested positive for Covid-19. On 2/6/24 during the noon meal service beginning at 11:55 AM, V15, Cook, was touching the outside of her face mask to adjust and readjust the mask, then handling resident drinking cups, glasses, and lidded cups without performing hand hygiene. V15 was touching, adjusting and readjusting her face mask then handling resident plates and insulated covers to stack on service carts without benefit of performing hand hygiene. V15 was touching, adjusting, and readjusting her face mask and eye protection glasses, then scooping and plating food from the steam table onto plates, then handling the plates of food to be served to residents. On 2/6/24 during the noon meal service beginning at 11:55 AM, V14, Dietary Aide, was reaching into her apron pocket to retrieve a writing utensil, then handling cups, glasses, and lids for the resident meal service, without benefit of performing hand hygiene, then returning the writing utensil to her pocket. V14 was reaching into her pocket to retrieve the writing utensil multiple times and then handling cups, glasses, and lids without performing hand hygiene. On 2/6/24 at 2:51 PM, V3, Dietary Manager, acknowledged the outside of a face mask is considered a contaminated surface. On 2/6/24 at 3:21 PM, V2, Director of Nursing/ Infection Preventionist, acknowledged and confirmed the outside of a face mask is considered contaminated and hand hygiene should be done after touching a face mask. On 2/6/24 at 3:21 PM, V16, Regional Nurse, stated, Our written policies probably wouldn't have anything that specific, but our policies follow the recommendations of the CDC (Centers for Disease Control and Prevention). The facility's policy Handwashing, dated 7/1/23, documents, To provide guidelines for adequate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 14 of 16 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 02/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm handwashing in order to reduce the transmission of organisms from resident to resident, staff to resident, and from resident to nursing staff. This facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash their hands after direct contact with any contaminated surface, after direct resident care, and as instructed. It is the responsibility of all staff to ensure they properly wash their hands after direct contact with residents, contaminated surfaces, and as needed. Residents Affected - Many The CDC current guidelines (2/8/24) document, HCP (Health Care Personnel) must take care not to touch their medical mask. If they touch or adjust their mask, they must immediately perform hand hygiene. The facility's current Resident Roster (undated) documents 62 residents reside in the facility, all of whom consume food prepared by the facility's kitchen service personnel. B. R12's Minimum Data Set (MDS), dated [DATE], documents R12 as cognitively intact. This same MDS documents R12 requires maximum assistance with toileting, bathing and dressing. R12's Physician Order Sheet (POS), dated February 2024, documents a physician order, dated 12/11/23, for contact isolation due to Carbapenem Resistant Enterobacteriaceae (CRE) in urine. R12's Care Plan intervention, dated 12/11/23, documents R12 was placed on contact isolation due to CRE in urine. On 02/06/24 at 12:00 PM, R12 was laying in bed in R12's room. R12's room did not have isolation barrels, isolation supply set up outside of room, or signs posted indicating R12 was on contact precautions. R12's indwelling urinary drainage system was visible from R12's doorway. On 2/6/24 at 12:10 PM, V10, Licensed Practical Nurse (LPN), assessed R12's indwelling urinary drainage system. V10, LPN, did not wear personal protective gown when assessing R12's indwelling urinary catheter system. V10, LPN's, scrub top touched R12's blankets and sheets as V10 adjusted R12's urinary catheter at tip of penis and manipulated R12's urinary catheter tubing. V10, LPN, did not wash hands or use hand hygiene when exiting R12's room. On 2/8/24 at 1:00 PM, V10, Licensed Practical Nurse (LPN), stated R12 was previously on Contact Isolation in another room for CRE in his urine. V10, LPN, stated, (R12) was moved rooms on 2/4/24 and his isolation set up did not get set up in his new/current room. (R12's) room should have had the Contact Isolation sign up, the isolation supply bin outside his room, and the red barrels in his room to dispose of soiled linens and garbage. V10, LPN, stated V10 knew of R12's previous room's isolation, and should have worn the correct Personal Protective Equipment (PPE) when caring for R12. The facility policy titled 'Transmission Based Precautions', dated 7/1/2023, documents, Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. It is the reasonability of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. A sign is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of Centers for Disease Control and Prevention (CDC) precautions, instructions for use of Personal Protective Equipment (PPE), and/or instructions to see a nurse before entering the room. Staff and visitors will wear a disposable gown upon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145546 If continuation sheet Page 15 of 16 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 02/09/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete entering the room and remove before leaving the room and avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. The facility policy titled 'Initiating Isolation Precautions Policy', dated 7/2/2023, documents Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist (IP) discontinues them, which occurs after criteria for discontinuation are met. Event ID: Facility ID: 145546 If continuation sheet Page 16 of 16