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. 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: 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 05/05/2025 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)