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Inspection visit

Health inspection

Allure Of ZionCMS #1454431 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145443 01/08/2025 Allure of Zion 3615 16th Street Zion, IL 60099
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to carry out a physician order for an Infectious Disease consultation for 1 of 3 residents (R2) reviewed for Quality of Care in the sample of 9. Residents Affected - Few The findings include: On 1/8/25 at 10:45 AM, R2 was in bed and appeared drowsy and unable to stay awake during a conversation with this surveyor. Outside of R2's doorway was a sign indicating she (R2) is on contact isolation. R2's urinalysis report dated 12/19/24 shows her urine tested positive for ESBL (extended-spectrum betalactamases) via a urine culture that was completed on 12/22/24. A facility provided timeline for R2 shows R2 had a Urinary Tract Infection (UTI's) on 9/11/24 which did not require treatment. One 10/25/24 which required antibiotic usage and another on 12/19/24 which also required antibiotic treatment, with Ertapenm sodium solution for 7 days. On 1/8/25 at 11:44 AM, V4 (Nurse Practitioner) stated she had been monitoring R2's increase in UTI's and her recent diagnosis of ESBL in her urine and decided she should refer her to an Infectious Disease doctor for further consultation as R2 has been overall declining. V4 stated a couple weeks ago she gave an order to V5 (Registered Nurse/RN) to start the referral process because it can take a while to get in to see the physician sometimes. V4 stated she was looking at R2's Physicians orders today and did not see that the order was ever entered by V5, so she entered it herself. V4 stated she expected when she gave the order to V5 she would enter it the same day and start the process and call for the appointment. V4 was able to indicate it was 12/26/24 when she gave V5 this order because of the charting in R2's medical record completed by V5. R2's nursing progress notes completed by V5 on 12/26/24 do not show any order or documentation about R2 being referred to an Infectious Disease doctor by V4. On 1/8/25 at 12:26 PM, V5 (RN) stated now that she thinks about it, she does remember V4 giving her an order for two residents to see the Infectious Disease doctor and that she (V5) did not enter the order for R2 and did not call for an appointment. On 1/8/25 at 2:31 PM, V2 (Director of Nursing) stated she was not aware before today of V5 not carrying out the order for R2 to see the Infectious Disease doctor. V2 stated she would expect nurses to carry out any physician order immediately and to start the referral process. Page 1 of 2 145443 145443 01/08/2025 Allure of Zion 3615 16th Street Zion, IL 60099
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/8/25 at 2:32 PM, V3 (Assistant Director of Nursing) stated the Infectious Disease doctors will sometimes do a tele health appointment which can be done usually pretty quick, and the facility also has transportation to get residents to appointments so if V5 had started the process R2 could have possibly been seen quick. The facility provided undated Consulting Physician/ Practitioner Orders policy that shows the nurse should note and carry out a physicians order. 145443 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ · About this visit

Common questions about this visit

What happened during the January 8, 2025 survey of Allure Of Zion?

This was a inspection survey of Allure Of Zion on January 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Allure Of Zion on January 8, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.