Inspection·March 28, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 obtain consent prior to the use of psychotropic medications for two of three residents (R1 and R2) reviewed for psychotropic medications in the sample of three. Residents Affected - Few Findings include: The facility's undated Use of Psychotropic Medication(s) documents the following: 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care,the treatment alternatives or other options and the preferred option to accept or decline, in a format the facility deems to use (e.g.written consent form, narrative note, etc.). R1's medical record documents R1's diagnoses include: Major Depressive Disorder, Bipolar Disorder Depressive State and Anxiety disorder. R1's medical record includes a MD (Medical Doctor)/Nursing Communication form for R1, dated 02/14/25 by V8 (the facility's Medical Director), documents V8's facility visit with R1 and an order to discontinue R1's Venlafaxine Hydrochloride Extended Release Oral Tablet 24-hour 150 mg/milligrams (an antidepressant medication). This visit note also included an order to initiate administration of Sertraline 50 mg orally once daily (an antidepressant medication). R1's Physicians Orders document R1's Venlafaxine was ordered upon R1's admission to the facility on [DATE], and was discontinued by V8/Medical Director on 2/14/25 and V8 ordered initiation of Sertraline 50 mg, which was started on 2/16/25. As of 3/28/25, R1's medical record did not contain documentation of a consent form for R1's Sertraline medication. On 3/28/25 at approximately 1:35pm V2 DON/Director of Nursing verified she was present with V8 on 02/14/25 and verified she received V8's orders to discontinue R1's Venlafaxine and initiate Sertraline. V2 stated consent for antidepressant medication administration changes should be obtained prior to initiating the medication orders. On 3/28/25 at approximately 2:35pm V2 stated the facility did not obtain consents from R1's Health Care Power of Attorney (R1's designated representative) prior to initiating the proposed medication changes. V2 stated the facility should have obtained consents for R1's change in medications. 2. R2's Diagnoses include: Major Depressive Disorder, Recurrent, Unspecified. (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 03/28/2025 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)