Health inspection·May 5, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses were provided for 2 of 3 residents (R2 and R3) with Stage 4 sacral pressure ulcers reviewed for pressure ulcers in the sample of 3. Residents Affected - Few The findings include: R2's admission Record dated 5/5/25 shows R2 was admitted to the facility on [DATE] with pressure induced deep tissue damage of her right heel and a Stage 4 pressure ulcer of her sacrum. R2's Specialty Physician Initial Wound Evaluation & Management Summary dated 2/27/25 shows the wound physician's, V10, plan of care for R2's Stage 4 sacral pressure wound includes a low air loss mattress. R2's care plan initiated on 2/27/25 shows R2 has a low air loss mattress as an intervention for her Stage 4 pressure wound of her sacrum. On 5/5/25 at 10:18 AM, V2, was lying in bed watching TV. V2 did not have a low air loss mattress on her bed. When asked if she had a special mattress for her bed, V2 replied, No. On 5/5/25 at 1:25 PM, V4, Wound Care Nurse, said every resident with a pressure wound goes on a low air loss mattress. V4 said R2 and R3 should all be on a low air loss mattress. V4 said they keep low air loss mattresses in the building and maintenance brings them up for the residents. On 5/5/25 at 1:38 PM, V4 walked down to R2's room to verify she does not have a low air loss mattress. V4 said R2 should be on a low air loss mattress, it is beneficial for a pressure ulcer. On 5/5/25 at 11:34 PM, R3 was sitting in her wheelchair in her room. R3 verified she does have a wound on her bottom. During this interview, V11, Maintenance, enters R3's room and proceeds to remove the mattress from R3's bed, which is not a low air loss mattress. R3 said she is getting a new mattress, an air mattress because the wound care doctor recommended it. R3 said she has been living in the facility for about a month. R3's admission Record dated 5/5/25 shows she was admitted to the facility on [DATE]. R3's Specialty Physician Initial Wound Evaluation & Management Summary dated 4/3/25 shows R3 has a Stage 4 pressure wound of her sacrum. V10's plan of care for R3's Stage 4 sacral pressure wound includes a low air loss mattress. The facility's Pressure Injury Prevention and Management Policy (undated) shows under the heading Interventions for Prevention and to Promote Healing, evidence-based interventions for all residents who have a pressure injury present include providing an appropriate, pressure-redistributing support surface. Page 1 of 2 145443 145443 05/05/2025 Allure of Zion 3615 16th Street Zion, IL 60099

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. Residents Affected - Few The findings include: R1's Order Summary Report dated 5/5/25 shows R1 has a current order for Enhanced Barrier precautions. R1's current care plan provided by the facility shows R1 has a Stage 4 pressure wound to her sacrum. On 5/5/25 at 9:56 AM, V4, Wound Care Nurse, V5, Certified Nursing Assistant (CNA), and V6, Life Enrichment were in R1's room assisting/changing R1's dressings. V6 was holding R1's leg, V5 was changing R1's left heel dressing. V5 assisted R1 to turn onto her side to allow visualization of R1's backside. V4, V5, nor V6 wore gowns while providing these direct cares. On 5/5/25 at 1:25 PM, V4 said residents with pressure wounds need to be on EBP. Staff should wear gowns and gloves while giving direct care to residents on EBP. On 5/5/25 at 1:42 PM, V3, Infection Prevention Nurse, said staff need to wear a gown, gloves, and mask when providing any close contact care to a resident on Enhanced Barrier Precautions (EBP). V3 said a resident with a wound that is a Stage 4 or greater requires EBP. V3 said the facility follows the CDC guidelines for EBP. The facility's Enhanced Barrier Precautions Policy (undated) shows EBP is an infection control intervention which employs gown and gloves use during high contact resident care activities. An order for EBP will be obtained for residents with pressure ulcers and PPE (personal protective equipment), gowns and gloves, is necessary when performing high contact care activities. High contact resident care activities include dressing, transferring, and wound care. 145443 Page 2 of 2