Health inspection·December 5, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide incontinence care to a resident (R1) that is dependent on staff for incontinence care. This applies to 1 of 3 residents reviewed for ADL's (Activities of Daily Living) in the sample of 3.The findings include: R1's electronic face sheet printed on 12/4/25 showed R1 has diagnoses including but not limited to Parkinson's Disease, congestive heart failure, major depressive disorder, hallucinations, and anxiety disorder.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, is incontinent of bladder, and requires staff assistance for personal hygiene.R1's care plan dated 7/22/24 showed, I have bladder incontinence .clean perineal area with each incontinence episode.On 12/4/25 at 10:10AM, R1 was sitting up in her (reclining wheelchair). The front of R1's pants were wet with an unknown substance and R1 had a strong urine odor.On 12/4/25 at 10:37AM, V4 (R1's daughter) stated, I have concerns with my Mom not being changed every 2 hours. She uses a (full body mechanical lift), and when they lift her up her pants are usually wet and the brief, she is wearing is brown and soaking wet.On 12/4/25 at 11:41AM, R1 was sitting up in her (reclining wheelchair) in the same position. The front of R1's pants were still wet. Surveyor notified (V5-Certified Nursing Assistant-CNA) that R1's pants were soiled.On 12/4/25 at 11:54AM, V5 came into R1's room and began wheeling her down the hallway. V5 stated R1 was not assigned to her; however, she believes R1 may have been changed around 8AM today. Surveyor questioned V5 as to if R1 gets changed in her room or the community bathroom and V5 stated, I will change her I guess but we usually change after lunch. V5 then brought R1 back to her room with V6 (CNA) and performed incontinence care. R1 was lifted up out of her chair and a strong urine odor was present. The front, back, and sides of R1's pants were wet. V5 and V6 removed R1's pants, revealing R1 was wearing 2 disposable incontinence briefs. V5 stated this is normal for R1 and that staff always put 2 briefs on her. When V5 removed R1's incontinence brief is was heavily soiled with urine and had a strong urine odor. At 12:23PM, V7 (CNA) stated she is assigned to care for R1 today and she has not provided incontinence care to R1 since her shift started at 8:00AM. V7 stated R1 is a night shift get up and is up before day shift arrives at 6:00AM every day.On 12/4/25 at 2:00PM, V2 (Interim Director of Nursing) stated, (R1) should not wear 2 incontinence briefs because that is just a way for staff to not have to change her as often. Her family never requested that. In my opinion, 6 hours is too long for a resident to go without being changed and even repositioned. This could contribute to urinary tract infections and skin breakdown.The facility's policy titled, Incontinence dated 2025 showed, Based on the resident's comprehensive assessment, all residents that are incontinent will receive the appropriate treatment and services.4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Residents Affected - Few 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 12/05/2025 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)