Inspection·September 8, 2024

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to employ a licensed Administrator. This failure has the potential to affect all 52 Residents residing in the Facility. Findings include: The Facility Resident Census Roster, dated [DATE], documents 52 Residents residing in the Facility. The Facility Department Head List, dated [DATE], documents that effective [DATE], V1 (Administrator in Training/AIT) is the Facility Administrator. The Facility Administrative Services Job Description, signed and dated [DATE] by V1 (AIT), documents: primary purpose of this position is to direct the day-to-day functions of the Facility in accordance with current Federal, State and Local standards, guidelines and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to Residents at all times; and must possess a current encumbered nursing home administrator's license or meet the license requirement of the state. On [DATE], the Facility could not provide V1's (AIT) Administrator's License or Administrator in Training License. The Facility provided V1's active Department of Professional Regulation Registered Nurse license. V1's (AIT) electronic email communication, dated [DATE], documents correspondence regarding V1's (AIT) payment to attend a Nursing Home Administration/NHA exam review course to prepare for NHA exam. V1's (AIT) electronic email communication, dated [DATE], documents correspondence regarding V1's (AIT) registration to attend the local State Nursing Home Administration Licensure Review course to prepare for State exam. On [DATE], at 1:50 pm, V7 (Administrator from the Facility's local sister facility) stated, I have an Administrator's license but I work at the other Facility here in town, I just help out this Facility at times, but I am not here full time. On [DATE] at 8:30 am, V1 (AIT) stated, I just took this Administrator's job on [DATE], and was I also was doing the Director of Nursing job at the same time for all of July, until we hired (V2/Director of Nursing). I just recently registered for the State and Federal review classes. I do not have a (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: 145012 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 145012 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Knox County 280 East Losey Street Galesburg, IL 61401 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)