Health inspection·June 26, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise a resident at high risk for falls for one of six residents (R1) reviewed for safety/supervision in the sample of six. This failure resulted in R1 experiencing a fall and rib fracture that resulted in R1 transferring to the local hospital. The findings include: R1's Discharge paperwork from the local hospital shows R1 was admitted to the local hospital from [DATE]-June 13, 2025, with diagnoses of wet gangrene, osteomyelitis, and dementia. R1's admission Record dated June 25, 2025, shows he was admitted to the facility on [DATE] with diagnosis of vascular dementia. R1's Fall Risk assessment dated [DATE], shows R1 was a high risk for falling with a score of 16. On June 25, 2025, at 12:44 PM, V9 Registered Nurse (RN) stated R1 arrived in the facility prior to her getting to the facility for her shift that started at 3:00 PM. V9 stated when she arrived for her shift, R1 had not been admitted by a nurse yet. V9 stated she did rounds on R1 first since he was not officially admitted by a nurse yet. V9 stated during report she (V9) was told R1 was a high fall risk. V9 stated she gave R1 a urinal, oriented R1 to his room and asked R1 to use the urinal and his call light. V9 stated she was at the nurse's station when the Certified Nursing Assistant (CNA) came and got her because R1 had fallen. V9 stated R1 reported head and back pain. V9 stated R1 was sent to the hospital since the fall was unwitnessed and R1 reported that he hit his head. On June 25, 2025, at 1:31 PM, V10 CNA stated she got to work at 2:00 PM and got report from the other CNA. V10 stated she got report that there was a new admission, but he had not been checked in by the nurse or CNA. V10 stated she asked the day nurse who was going to do R1's admission, and the day nurse said the 2nd shift nurse was going to do R1's admission. V10 stated that R1 was at the facility before her shift started at 2:00 PM. V10 stated the nurses get to the facility at 3:00 PM. V10 stated that at the time of R1's fall on June 13, 2025, she was performing incontinence care to R1's roommate. V10 stated she could hear R1 trying to get up from his bed because she could hear the mattress creaking. V10 stated she looked around the privacy curtain and asked R1 if he needed something. V10 said that R1 was sitting on the edge of the bed. V10 said that R1 told her that he needed to use the bathroom. V10 said she told R1 to use his urinal. V10 said she did not know if R1 could walk or not because he had not been evaluated by the nurse yet. V10 said there was a walker by R1's closet but she was not sure if it was R1's or not. V10 said she asked R1 if he wanted to use the walker and unfolded it. V10 said that R1 was still trying to get up without the walker when V10 left the room (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 3 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 06/26/2025 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)