Inspection·April 18, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect a resident's right to be free from physical abuse for one of four residents (R3) reviewed for abuse in the sample list of eight. Findings Include: The facility's Abuse Policy dated 1/9/24 documents it is the responsibility of the facility staff to assure that all residents remain free from abuse. The facility affirms the right of its residents to be free from abuse. Abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury. Physical abuse is the infliction on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, and kicking. The facility's Final Report and Conclusion of Incident form dated 3/7/25 documents on 3/2/25 at 12:30 PM R3 reported she was sitting in the dining room in her normal spot at the table when R2 came over in her wheelchair and told her to get out of her spot. R3 did not move and R2 swung and hit R3 in her left arm with a closed fist. R3 yelled out for staff and staff intervened and separated R2 from R3. R2's Medical Diagnoses Sheet dated April 2025 documents R2 is diagnosed with Dementia. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. R3's Medical Diagnoses Sheet dated April 2025 documents R3 is diagnosed with Depression, General Anxiety Disorder and Post Traumatic Stress Disorder (PTSD). R3's Minimum Data Set, dated [DATE] documents R3 is cognitively intact. R3's Care Plan dated 6/12/24 documents R3 has the potential for abuse/neglect due to a personal history of: Depression, Physical Vulnerability such as poor ambulation or inability to ambulate/propel wheelchair, frailty/weakness, prior physical abuse, prior sexual abuse, and prior verbal abuse. R3 has a history that indicates she has experienced significant trauma during her lifetime. Specifically, trauma related to experience flashbacks, involvement in a major accident, a life event that has caused lasting significant anxiety, depression, sleeplessness or fear, PTSD, as well as an unexpected loss of a loved one, victim of domestic violence, victim of sexual assault, and victim of verbal assault. (continued on next page) 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 2 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 04/18/2025 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)