Allure Of Zion

In the surveyor’s words

From the most serious findings on record at Allure Of Zion, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880May 4, 2021

  Based on observation, interview, and record review the facility failed to follow recommended guidelines from Centers for Disease Control (CDC) by not ensuring staff were wearing N95 face masks and isolation gowns per recommendations while caring for residents that are positive with COVID-19, residents on transmission based precautions (contact/droplet) because of a known exposure to a positive COVID-19 staff member, and while doing COVID-19 testing on staff members with an unknown COVID-19 status. The facility also failed to ensure staff are reporting known exposures to COVID-19 positive and signs of illness before working with negative COVID-19 residents. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. […]

• Immediate jeopardy, isolatedF697Oct 23, 2023

  Based on interview and record review the facility failed to clarify a resident's pain management orders with the primary care physician prior to administering additional opiate pain medications and failed to discontinue a residents pain patch. These failures resulted in R2 experiencing a mental status change, lethargy, and required emergent hospitalization for suspected opiate overdose. This applies to 1 of 6 residents (R2) reviewed for pain management in the sample of 13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/10/23, when V20 (Registered Nurse/RN) failed to clarify R2's Morphine (pain medication) plan of care prescription from a pain consultant with her primary care physician prior to carrying out the order. […]

• Actual harm, isolatedF689Jun 26, 2025

  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. […]

• Actual harm, isolatedF686Jul 12, 2024

  Based on observation, interview, and record review, the facility failed to identify areas of pressure for 2 of 3 residents (R45, R56) reviewed for pressure in the sample of 24. This failure resulted in R45 developing two stage 4 pressure injuries, one on each heel, requiring surgical debridement to remove non-viable tissue, and R56 developing an unstageable pressure injury to her left hip requiring debridement. The findings include: 1. R45's Admission Record, provided by the facility on 7/11/24, showed she had diagnoses including a stage 4 pressure ulcer of right heel, and a stage 4 pressure ulcer of left heel, protein-calorie malnutrition, acute embolism, and thrombosis of unspecified deep veins of left lower extremity, and bilateral primary osteoarthritis of knees. […]

• Actual harm, isolatedF692Jul 12, 2024

  Based on observation, interview, and record review, the facility failed to perform weekly weights as ordered by a physician for 1 of 7 residents (R58) reviewed for nutrition in the sample of 24. This failure resulted in R58 experiencing a significant weight loss of 7.96% within a 3-month period before it was identified by facility staff and R58 was referred to the facility dietician. The findings include: R58's electronic face sheet printed on 7/11/24 showed R58 has diagnoses including but not limited to traumatic subdural hemorrhage, type 2 diabetes, unspecified protein-calorie nutrition, anemia, and history of pneumonia. […]