Health inspection·December 18, 2025

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor dementia residents with wandering behaviors. The facility failed to immediately intervene and redirect dementia residents exhibiting wandering and dementia related behaviors. These failures apply to 2 of 3 residents (R1, R2) reviewed for dementia care in the sample of 4.The findings include:A facility report dated 12/8/25 showed V13 Certified Nursing Assistant (CNA) observed R1 lying next to R2 in R2's bed. R1 and R2 were fully dressed. The report showed video surveillance of the incident, reviewed by V1 Administrator, showed R1 entered R2's room at 5:31 AM on 12/8/25. R1 was not removed from R2's room by facility staff until 6:03 AM. R2 exited her room at 5:52 AM, on her own will. The report showed R1 and R2 both had a diagnosis of dementia.R2's admission record showed R2 was admitted to the facility on [DATE] and discharged home with family on 12/17/25. R2's care plan dated 11/24/25 showed R2 was cognitively impaired related to her diagnosis of dementia. R2's progress notes dated 11/22/25, 11/24/25, and 11/30/25 showed R2 would attempt to get up on her own and could propel herself in her wheelchair throughout the facility. R2's 11/30/25 note showed R2 was confused, keeps on going to other resident room, calling other male resident her husband.R1's care plan dated 10/16/25 showed R1 was severely cognitively impaired related to his diagnosis of dementia. The plan showed R1 wanders aimlessly throughout the building. The plan showed facility staff were to distract R1 from wandering, offering him pleasant diversions, and intervene as appropriate. Progress notes dated November 7, 16, and 29, 2025 showed R1 was found wandering at night throughout the facility.On 12/18/25 at 9:08 AM, this surveyor attempted to interview R1 about the incident on 12/8/25 however R1 could not be interviewed due to his impaired cognition. R1 was confused to person, place and time. R1 stated he didn't know R2. R1 denied any recollection of the incident on 12/8/25, stating, I don't remember anything.On 12/18/25 at 9:35 AM, V8 CNA stated on 12/8/25 she found R1 lying in R2's bed, fully dressed. V8 stated R2 was dressed, seated in her wheelchair, next to R1 as he laid in her bed. V8 stated she tried to get R1 out of R2's bed but R2 got verbally aggressive with V8. V8 stated she left R2's room and reported her findings to V9 Registered Nurse (RN) but (V9) was busy passing meds so I waited for the day shift to come in so they could help me get (R1) out of the bed. V8 stated she had no idea how long R1 had been in R2's room.On 12/18/25 at 9:49 AM, V9 RN stated on 12/8/25 he observed R1 lying in R2's bed. R2 was seated in a wheelchair in the room. V9 stated he did not immediately attempt to intervene or remove R1 from R2's bed because while V9 was aware R1 and R2 were severely cognitively impaired related to their dementia diagnoses, V9 stated, I didn't know if they were in some type of relationship. V9 stated he had no idea how long R1 had been in R2's room. V9 stated he knew both R1 and R2 had a history of wandering behaviors.On 12/18/25 at 12:28 PM, an attempt to contact V13 CNA via phone for an interview was unsuccessful.On 12/18/25 at 12:05 PM, V1 Administrator stated the facility no longer had video of the incident on 12/8/25 involving R1 and R2 for this surveyor to review. V1 stated he watched facility video Residents Affected - Few (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 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 12/18/2025 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)