Health inspection·February 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure incontinent supplies were available for one of three residents reviewed for dignity (R42) in the sample of 25. Findings include: An undated policy titled Resident Rights in a section titled Respect and dignity documents, 4. c. The resident has a right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. R42's MDS/Minimum Data Set assessment dated [DATE] documents R42's BIMS/Brief Interview for Mental Status as 15 out of 15, indicating no cognitive impairment. R42's MDS dated [DATE] documents R42 is frequently incontinent of bowel and bladder. R42's Nutritional assessment dated [DATE] documents R42 is 62.5 inches tall. R42's weight documented on 02/04/24 is 226.5 pounds. On 02/13/24 at 11:26 AM, R42 stated, The facility does not have size 2XL (two extra-large) (incontinence briefs) or (cleansing) wipes. They always run out and I have to buy my own. On 02/13/24 at 3:12 PM, V11/Registered Nurse looked in the middle hallway stock room for 2XL incontinence briefs and cleansing wipes. V11 stated she could not find any but would look at the front nurses' station. V11 walked to the front nurses' station and asked V12/Licensed Practical Nurse if she could provide cleansing wipes. V12 stated, We're out. There are none. On 02/13/24 at 3:17 PM, V13/Certified Nursing Assistant stated, There were a few (cleansing wipes) left on Friday when I worked. I'm guessing they ran out on the weekend. V13 was asked if they had 2XL incontinence briefs. V13 stated the facility is out and has trouble receiving them from the vendor. V13 could not recall the last time the facility had size 2XL incontinent briefs. Page 1 of 13 145012 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review and interview, the facility failed to ensure a resident was free of physical abuse for one (R14) of four residents reviewed for abuse in a sample of 25. Residents Affected - Few Findings include: An undated Abuse, Neglect and Exploitation policy documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The definition of abuse is documented as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. R14's BIMS/Brief Interview of Mental Status, dated 1/30/24, documents R14's BIMS score is 14 out of 15, indicating R14 is cognitively intact. R27's BIMS, dated 12/20/23, documents R27's BIMS score is 11 out of 15, indicating moderate cognitive impairment. Facility Reported Incident, dated 02/08/24, documents, Resident to resident - room mates (R14 and R27) reportedly hit each other. Were separated no injury noted investigation initiated final to follow. Final Incident Investigation, dated 02/15/24, documents, (R14 and R27) were roommates in (number of room). The nurse on duty heard (R14). Per (R14's) interview - (R14) had just returned from bingo and wheeled to (R14's) room. (R14) needed to use the restroom and couldn't reach (R14's) call light as (the) roommate (R27) was in the way. (R14) reports that (R27) swatted at (R14) and made contact with (R14's) left arm. (R14) indicated her left upper arm by pointing at it. (R14) also reported that (R27) hit a nurse, too. (R14) denies hitting (R27). Final Incident Investigation, dated 02/15/24, documents R27's interview as, (R27's) previous roommate was constantly telling me I couldn't be in my room. (R14) would always interrupt when I have visitors. I hit (R14) out of frustration, I didn't mean to hurt her. (R27) reports that (R14) was swinging at (R27) as well. On 02/13/24 at 11:41 AM, R14 stated she was fine now that they got (R27) out of here. R14 was pointing toward the empty bed near the window. R14 reported coming back from bingo and could not reach the call light. R14 stated R27 was in the way, R27 picked up R14's call light and whacked me. R14 pointed to R14's right upper arm. On 02/15/24 at 12:40 PM, R27 stated, (R14) interrupted every time I had visitors and always told me I couldn't stay in the room. I hit (R14) because I was frustrated. R14's Progress Note, dated 02/08/24 at 4:45 PM, documents: (R14) said another resident hit her with her call light on the left (forearm) and left a red mark on her LFA (left forearm). No c/o (complaints of) pain. POA (Power of Attorney) was notified and Administrator/V1. (R27) was moved to another 145012 Page 2 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0600 room. Middle station nurse said she heard (R14) yelling 'Stop hitting me'. Nurse moved (R27) to another room. And notified (R14's) family. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145012 Page 3 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow their abuse policy for one (R47) of three residents reviewed for abuse in a sample of 25. Residents Affected - Few Findings include: Facility Abuse, Neglect, and Exploitation policy, copywrite 2023, documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Investigation of Alleged Abuse, Neglect and Exploitation written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. V1's email to state, dated 1/8/24 at 3:03 PM, documents On 1/5/24 (V9/R47's friend) reported (R47) was missing money from his wallet. Investigation initiated. Upon interview with (R47), who is currently in the hospital, reported to (V10/ Hospital Liaison) he had $100 in cash in his wallet in $10 increments, brand new bills with matching serial numbers as he prints them out himself. Due to (R47's) statement this allegation is unsubstantiated. No other residents or staff interviewed as part of this investigation. On 2/16/24 at 11:29 AM, V1 Administrator stated I did not interview any other residents or staff as part of this investigation because it was a joke to (R47). 145012 Page 4 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review and interview, the facility failed to report the misappropriation of money to the local State Agency for one of four residents reviewed for abuse (R42) in a sample of 25. Residents Affected - Few Findings include: An undated Abuse, Neglect and Exploitation policy documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A section of this policy titled Reporting/Response documents, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R42's MDS/Minimum Data Set Assessment, dated 12/04/23, documents R42's BIMS/Brief Interview for Mental Status as 15 out of 15 indicating R42 is cognitively intact. On 02/13/24 at 11:26 AM, R42 stated, I had $120.00 stolen from me last fall. R42 stated the money was discovered missing in August 2023 around the time R42 fell and went to the hospital for X-Rays. R42 stated the money was kept in a coin purse inside of a zippered pouch attached to R42's wheelchair and discovered missing approximately four days after the fall. R42 stated the missing money was reported to V19/Former Administrator. On 02/13/24 at 3:45 PM, V6/Activities Director stated she recalled R42 reported that she was missing money last fall. V6 stated she thought she remembered the issue being discussed during a morning meeting. V6 confirmed V19/Former Administrator was the Administrator at the time, however, no longer employed by the facility. On 02/14/24 at 3:12 PM, V14/Regional Nurse Consultant, confirmed the facility could not provide evidence that R42's missing money was reported to the local State Agency. 145012 Page 5 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm 2. R42's MDS/Minimum Data Set Assessment, dated 12/04/23, documents R42's BIMS/Brief Interview for Mental Status as 15 out of 15, indicating R42 is cognitively intact. Residents Affected - Few On 02/13/24 at 11:26 AM, R42 stated, I had $120.00 stolen from me last fall. R42 stated the money was discovered missing in August 2023 around the time R42 fell and went to the hospital for X-Rays. R42 stated the money was kept in a coin purse inside of a zippered pouch attached to a wheelchair and was discovered missing approximately four days after the fall. R42 stated the missing money was reported to V19/Former Administrator. On 02/13/24 at 3:45 PM, V6/Activities Director, stated she recalled R42 reported that she was missing money last fall. V6 stated she thought she remembered the issue being discussed during a morning meeting. On 02/14/24 at 3:12 PM, V14/Regional Nurse Consultant confirmed she could not provide evidence that the facility investigated the money R42 reported missing in August 2023. Based on interview and record review, the facility failed to conduct a thorough investigation into an allegation of misappropriation of property for two (R47 and R42) of three residents reviewed for abuse in a sample of 25. Findings include: Facility Abuse, Neglect, and Exploitation policy, copywrite 2023, documents Investigation of Alleged Abuse, Neglect and Exploitation written procedures for investigations include: Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Providing complete and thorough documentation of the investigation. Misappropriation of Resident Property is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. 1. V1 Administrators email to state, dated 1/5/24 at 8:02 PM, documents (R47) was in the hospital and his friend reports missing money. Investigation started, final to follow. V1's email to state, dated 1/8/24 at 3:03 PM, documents On 1/5/24 (V9/R47's friend) reported (R47) was missing money from his wallet. Investigation initiated. Upon interview with (R47), who is currently in the hospital, reported to (V10/ Hospital Liaison) he had $100 in cash in his wallet in $10 increments, brand new bills with matching serial numbers as he prints them out himself. Due to (R47's) statement this allegation is unsubstantiated. No other residents or staff interviewed as part of this investigation. On 2/13/24 at 12:55 PM, R47 was in his room, alert and oriented, and stated I don't have a problem with missing money anymore, that has been taken care of. On 2/16/24 at 11:29 AM, V1 Administrator stated I did not interview any other residents or staff as part of this investigation because it was a joke to (R47). I am aware other residents have complained of missing items and money. I am investigating them, interviewing staff, and interviewing residents on those incidents. That is usually what I do as part of the investigation. 145012 Page 6 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop a smoking careplan for one (R47) of 24 residents reviewed for careplan development in a sample of 25. Residents Affected - Few Findings include: Facility Comprehensive Care Plans, Copyright 2023, documents It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident to meet the residents medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. On 2/13/24 at 11:32 AM, R47 stated I am a smoker for 40 years, they keep my smoking materials locked up, and I have to ask for them. During this survey from 2/13-2/16/24 from 9 AM-PM, multiple observations were made of R47 smoking outside. On 2/14/24 at 9:33 AM, R47 was outside on the smoking patio smoking and holding smoking materials. R47's MDS/Minimum Data Set documents R47 is a smoker. Facility Smokers paper, no date, has R47 listed. R47's current care plan does not have smoking careplanned. On 02/16/24 at 11:27 AM, V14 Regional Nurse stated I don't see smoking on the careplan. We will get that taken care of. On 2/16/24 at 11:27 AM, V4 MDS/Careplan's stated I assume smoking should be on the careplan. 145012 Page 7 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

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 observation, interview, and record review, the facility failed to ensure a resident was free of injury from electrical devices for one of three residents (R40) reviewed for accidents and supervision in the sample of 25. This failure resulted in R40 sustaining a burn injury to R40's left leg/buttock region after R40 was positioned with a cellular phone charging cube that was plugged into an electrical outlet with use of an extension cord directly under R40's upper leg. After R40 was incontinent of urine, R40's cellular charging cube came into direct contact with liquid, causing the electrical appliance to spark and smoke, resulting in the burning of R40's skin. R40's burn injury has required multiple surgical debridements. Findings include: The facility's Electrical Safety for Residents Policy revised [DATE] states, Policy Statement: The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns, and fire. The facility's Risk Management Incident Report Log documents R40 with a burn on [DATE] at midnight hours. R40's admission Record documents R40 admitted to the facility on [DATE] with diagnoses to include but not limited to: Type 2 Diabetes Mellitus with Diabetic Neuropathy; Critical Illness Polyneuropathy; Neuromuscular Dysfunction of the Bladder; Anemia; and Protein-Calorie Malnutrition. R40's Minimum Data Set/MDS Assessment, dated [DATE] and [DATE], documents the following: R40 is cognitively intact and R40 is dependent on staff to roll left and right in bed. Dependent is described as Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity. R40's Risk Management Report created by V18/Agency Licensed Practical Nurse/LPN, states, Burn and is dated [DATE]. This same report states, (R40) had cell phone power cord underneath (R40's) left buttock, cord got wet from urine, and created a burn. The facility's Initial and Final Report to the local State Agency, dated [DATE], documents that on [DATE], R40 requested to be repositioned and reported feeling a burning sensation to buttocks. This same report documents that R40 had a cell phone charging block underneath him across the bed and plugged into an extension cord. R40 reported that when R40 was incontinent of urine, the urine entered the charging port thus causing a burn to R40's buttocks. R40's COMS-Skin Only Evaluation dated [DATE], [DATE], and [DATE] documents R40 with current skin issues of a burn to R40's left buttocks. R40's Wound-Weekly Observation Tool dated [DATE] documents R40 acquired a burn to R40's left buttock on [DATE]. The facility's Professional/General Liability Insurance Report Form documents R40 was involved in a resident injury or incident on [DATE]. This same report documents incident and injury description 145012 Page 8 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0689 as (R40) obtained an electrical burn after lying on a phone charger plugged into an extension cord after urinating thus causing the electrical burn. Level of Harm - Actual harm Residents Affected - Few V20's (R40's Nurse Practitioner) visit note, dated [DATE], states, Chief Complaint: I (R40) received a burn from my charger being in bed. This same note states, (R40) is being seen today as he suffered a burn to his (left) buttock. (R40) was in his room this morning lying in bed propped up on his side as he reports he has a burn on his (left) buttock as he was laying on his phone which was on the charger. Due to (R40) being incontinent he reports that it caused this (burn) to occur. (R40) did report that his charger was plugged into an extension cord he had from home as he wanted to be able to be on his phone while in bed as it was charging. V1's (Administrator) Incident Follow-Up Note dated [DATE] states, Spoke with (R40) regarding the incident that occurred on [DATE]. (R40) stated he had his cell phone charging block plugged into an extension cord. It was not the extension cord, but the cell phone block that was inadvertently underneath him. When (R40) was incontinent, the urine ran into the cell phone charger and caused the issue. R40's Health Status Note signed and dated by V18/Agency LPN on [DATE] at 2:22 AM, states, (V15/R40's Spouse) removed (R40's) dressing to take pictures of wounds. Dressing reapplied. Open wound continues. Wound edges are now raised and hardened. Several small blisters appearing toward distal end of wound. R40's Health Status Note signed and dated by V18 on [DATE] at 11:44 PM, states, During rounds (R40) requesting to be repositioned and reported burning to buttocks. Staff observed (R40) laying on top of extension cord that then began to smoke and spark due to (R40's) urinary incontinence. Extension cord removed from wall and then from under (R40). Upon Assessment, 3.5 cm/centimeter x (by) 5 cm open area noted to (left) lower buttocks. 3 cm x 2 cm blistered area noted just above open area to (left) buttock. Skin surrounding both wounds red and thin. (R40) does report stinging and discomfort to both areas. Sites cleansed. TAO (Triple Antibiotic Ointment) applied, and then open area covered with bordered foam. R40's Order Summary Report dated [DATE]-[DATE] documents an order for Santyl Ointment 250 Unit/GM (per Gram). Apply to left upper thigh topically every day shift for wound treatment-cleanse with 0.25% (percent) Dakins Solution-apply Santyl then Calcium Alginate-Cover with (foam) border dressing qd (every day). V21's (R40's Wound Physician) Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness. Etiology: Burn. Further Etiology Detail: From shorted out charging station. Wound Size (L x W x D/Length by Width by Depth) 5 cm x 6 cm x 1 cm. Surface Area: 30 cm squared. Exudate: Light Serous. Thick Adherent Black Necrotic Tissue (Eschar): 75 % (percent). Thick Adherent Devitalized Necrotic Tissue: 10 %. Granulation Tissue: 15 %. This same note documents a Surgical Excisional Debridement Procedure was performed on R40's wound on [DATE] to remove necrotic tissue and establish margins of viable tissue, remove thick adherent Eschar and devitalized tissue. This note is documented as an initial evaluation. V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock-Improved Evidenced by Decreased Necrotic Tissue, deceased Surface Area, Full Thickness. R40's wound size measured 4.1 cm x 5.1 cm x 0.1 cm. This same note documents a Surgical Excisional Debridement Procedure to R40's wound was performed on [DATE]. 145012 Page 9 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0689 Level of Harm - Actual harm Residents Affected - Few V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness and documents a Surgical Excisional Debridement Procedure was performed on [DATE] to remove necrotic tissue and establish the margins of viable tissue. V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness and documents a Surgical Excisional Debridement Procedure was performed on [DATE] to remove necrotic tissue and establish the margins of viable tissue. On [DATE] at 9:42 AM, R40 was observed sitting up in bed watching R40's cellular phone which was positioned on a bedside table in front of R40. R40 stated at the end of [DATE], R40's phone was plugged into an extension cord and in the bed with R40. R40 stated R40 was positioned on top of the block that was charging R40's phone. R40 stated when R40 urinated, the urine ran right into that charging port. I got third degree burns because of it. R40 stated R40 has decreased sensation, couldn't feel the cord under R40, and that R40 wasn't able to reposition off the charging cord/cube himself. R40 stated, I was calling for help because I couldn't get off it (phone charging device). I felt a tingling sensation initially, then it started burning really bad. My roommate at the time (R51) turned on his call light for me and got the girls to help me. He said, 'he needs help right now.' I take Norco to help with the pain and they do wound treatments every day. It is getting better. The treatments used to be every shift. R40 stated he had been using his phone cord and extension cord for months and denied that anyone ever said anything to him about their use. On [DATE] at 9:57 AM, V4 (Licensed Practical Nurse) entered R40's room to change R40's wound dressing. R40's soiled dressing was removed, and an approximate golf-ball sized open wound was noted. R40's open wound was noted with a straight edge, resembling a partial square shape on the proximal edge. R40's wound tissue was pinkish red with slight serous drainage noted. While V4 was cleansing and dressing R40's wound, R40 was observed grimacing, moaning, and tensing up/pulling away from V4's touch. On [DATE] at 10:51 AM, V3 (Assistant Director of Nursing) stated V3 had received a phone call in the early morning on [DATE] due to being the on-call nurse. V3 stated V3 could not remember who called V3, but V3 was called to be informed that R40's family was in the facility taking pictures of R40's newly acquired wound. On [DATE] at 10:25 AM, V15 (R40's Spouse) stated R40 had called V15 and told V15 that R40 was burned from his phone cord being under him. V15 stated, I came in and took pics (pictures). (R40) said the lady (V17/Certified Nursing Assistant) who took care of him rolled him over onto his phone cord after she changed him. Nothing should be in his bed or under him, they should make sure he is clear before they leave the room. V15 stated R40 admitted with the extension cord and phone charger back in [DATE]. It (Phone Charger and Extension Cord) had been there for months, and no one ever said anything to me or (R40) about it. We didn't know what we could or couldn't have. On [DATE] at 10:41 AM, V13 (Certified Nursing Assistant/CNA) stated that V13 was aware that R40 used a phone cord charger and cord that plugged into the wall in R40's room. On [DATE] at 12:03 PM, V16 (CNA) stated, I was walking up the hall and (V17/CNA) stepped out and asked me to help pull (R40) up in bed. She said she had just changed him. After, (R40) had his light on and asked for a snack. He said his left leg was 'cramping.' I tried helping him, but then said I would let his nurse know because there wasn't much more I could do for cramps. I left to answer another light. Maybe five minutes or so later, (R40) had his light on again, and his roommate (R51) was 145012 Page 10 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0689 Level of Harm - Actual harm Residents Affected - Few yelling, 'Can you help him?' When I went into the room (R40) was yelling, 'it burns, it burns.' I said, 'where is it burning at?' and (R40) said under his bottom. That's when I noticed his phone cord was sparking and smoking. I ripped it out of the wall and then pulled it out from under him. (R40's) phone was connected to a dual head charging cube and that is where the smoke and sparks were coming from. I could smell the smoke. I couldn't see his skin until I rolled him over with the nurse. There was an inch and a half-sized blister. When we looked at it again later in the night it was more open and looked worse. I don't usually work with (R40). (V17) had just changed him. I was at the nurse's station and went back again when (R51) turned the call light on for (R40). I wrote out two handwritten reports. I gave one to my nurse (V22/Licensed Practical Nurse) and I gave the other one to (V4/LPN). I was able to pull out the cord from under (R40) easily. It shouldn't have been under him; I didn't notice it at first when I went in to pull him up the first time. On [DATE] at 9:41 AM, V17 (CNA) stated on [DATE], V17 had repositioned (R40) in bed. V17 stated R40 had wanted to turn on R40's side. I believe he was lying on his back and wanted to turn on his side. A little bit after, (R40) had his light on again, another CNA (V16) I was working with answered the light that time. V17 stated, I didn't see it (the wound or burning cord), but I asked what happened and (V16) said it was smoking. V17 stated V17 recalled R40 having a charger that was in bed with R40 because V17 had to move it to reposition R40 initially. On [DATE] at 12:30 PM, V1 (Administrator) stated that R40 should not have been using an extension cord in R40's room. V1 stated, We are a team, so we should have noticed it too. V1 also stated R40 was burned when R40's urine went into the port where R40's cellular phone cord was plugged into the extension cord. V1 verified R40's cellular phone cord had been positioned under R40 inadvertently. Attempts to speak with V18 (LPN) and V22 (LPN) on [DATE] and [DATE] were unsuccessful. No callbacks were received. 145012 Page 11 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review, and interview, the facility failed to provide/have quarterly Quality Assurance & Performance Improvement (QAPI) meetings. This failure has the potential to effect all 53 residents residing in the facility. Residents Affected - Many FINDINGS INCLUDE: Facility policy, entitled 2023 Quality Assurance & Performance Improvement (QAPI) Plan, Copyright 2022, document, Committee meetings are held on a quarterly basis at a minimum. The committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress notes. QAPI sign-in sheets provided only include one sheet/one quarter. No other documentation for QAPI meetings was able to be found/provided. On 2/15/2024, V14/Regional Nurse Consultant confirmed the facility does not have QAPI meeting sign-in sheets for three of the four quarters in 2023. V14 also confirmed sign-in sheets should have been completed and maintained in the facility. The Centers for Medicare and Medicaid Services/CMS form 671-Long-Term Care Facilities Application for Medicare and Medicaid, dated 2/14/2024, document 53 residents reside in the facility. 145012 Page 12 of 13 145012 02/16/2024 Allure of Knox County 280 East Losey Street Galesburg, IL 61401

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to evaluate residents for smoking safety for one (R47) of two residents reviewed for safe smoking in a sample of 25. Residents Affected - Few Findings include: Facility Resident and Visitor Smoking Policy Notification, undated, documents Residents who pose a hazard with smoking materials will have supervised smoking times, and placed in a supervised program for safe smoking. Facility Smokers paper, undated, has R47 listed. On 2/13/24 at 11:32 AM, R47 stated I am a smoker for 40 years, they keep my smoking materials locked up, and I have to ask for them. During this survey from 2/13-2/16/24 from 9 AM-PM, multiple observations were made of R47 smoking outside. On 2/14/24 at 9:33 AM, R47 was outside on the smoking patio smoking and holding smoking materials. R47's medical record has no smoking assessment as part of the chart. On 2/16/24 at 11:27 AM, V14 Regional Nurse stated I don't see a smoking assessment for (R47). (V5) Social Services Director/SSD does the smoking assessments. On 2/16/24 at 11:28 AM, V5 SSD stated I am supposed to do the smoking assessments, and I must have missed (R47's). 145012 Page 13 of 13