Health inspection·December 4, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on interview and record review the facility failed to ensure a resident was notified in writing of a facility-initiated room change and failed to ensure the resident was shown the new room and introduced to her new roommate before the room change for 1 of 3 residents (R1) reviewed for room changes in the sample of 9. The findings include: R1's Census Report shows that she was transferred to another room on 11/25/24. On 12/4/24 at 9:30 AM, R1 stated that a male resident came into her room and kissed her on the cheek and after the facility heard about the incident, they made her change rooms so R2 could not find her. R1 stated that she was upset because she didn't understand why she had to change rooms when she did not do anything wrong. R1 stated that she really liked her previous room because she had a nice view out the window. R1 stated that after her room transfer, she did not get along with the other resident in the room due to her keeping her TV very loud. R1 stated that she could not hear her visitors nor her own TV. R1 stated, I feel like I am getting punished for what happened. R1 stated that she did not get to see her new room or get introduced to her new roommate before she was transferred. R1 stated that she never received anything in writing about the room change. On 12/4/24 at 1:19 PM, V4 (Social Service Director) stated that the team had met and decided to move R1's room after the incident between R1 and R2. V4 stated, We always move the complainer. V4 stated that the admissions director fills out a form, but she is not sure if the resident gets a copy of the form or not. At 1:35 PM, V4 stated that she verified with admissions, and they do not give the resident anything in writing about the room change. V4 stated that the form is only filled out and filed for their records. R1's Room Change Notification Form shows that R1's room was changed on 11/25/24 and the reason for the change was due to bed management. There was no documentation in R1's electronic medical record regarding the room change on 11/25/24. The facility's undated Change of Room or Roommate Policy shows, The notice of change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required. Social Service staff will assist the resident to adjust to the new room or roommate by:. Involving the resident in the decision and selection of a room or roommate when possible Showing the resident where the room is located (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 4 Event ID: 145443 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 145443 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Zion 3615 16th Street Zion, IL 60099 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)