Inspection·July 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light in room (5/13/25); likes to stay up late, if still up after 9:00 pm, offer to assist to bed, if wishes to stay up later, offer R1 assistance to bed at intervals, monitor and assist for footwear (5/17/25); assist toilet after breakfast and monitor going to room to lie down (5/17/25); provide education to ask for assistance (5/21/25); monitor for R1 in TV room and offer to assist into chair (5/21/2025; lower back of wheelchair to keep from sliding out( 7/07/2025); bed in low position (4/07/2025); non-skid pad under wheelchair cushion and on top of wheelchair cushion (6/14/2025); observe for resident showing signs of fatigue and offer to assist to bed (4/30/2025); non-skid pad (dycem) in wheelchair seat (5/27/2025); medication review (Hydroxyzine) at hours of sleep (6/27/2025); monitor for resident trying to propel wheelchair with brakes locked (6/27/2025); have commonly used articles within easy reach (4/07/2025); provide assistance to transfer and ambulate as needed (4/07/2025); Staff education (6/15/2025).R1's Neurological Evaluation Flow Sheets, dated 4/1/25 through 7/18/25, do not document neurological checks for R1's un-witnessed falls on 4/29/25, 5/1/25, 5/13/25and 7/8/25.R1's Un-witnessed Fall Report (#367), dated 4/29/25 at 1:50 pm, documents R1 was noted to be sitting on the floor next to bed and stated, I was trying to get into bed and my foot went out from under me. No injuries were noted. The intervention was to observe for signs/symptoms of fatigue and offer assist to bed. R1's Un-witnessed Fall Report (#370), dated 5/1/25 at 10:40 pm, documents R1 was sitting in wheelchair at end of hallway and self-transferred standing up to walk and states was trying to answer the phone and the kids were calling. No injuries were noted. The intervention was to provide a tray table in corridor and provide activities (coloring books, markers/crayons an puzzles).R1's Un-witnessed Fall Report (#387), dated 5/13/25 at 4:20 am, documents R1 was noted sitting on bottom at foot of bed by door, call light not on, wearing shoes, incontinence brief dry. R1 stated that R1 stood up on the right side of the bed and was heading out to the hallway, R1 fell then scooted to the doorway. R1 was confused on time. No injuries were noted. The intervention was that staff sat with R1 until ready to return to bed.R1's Un-witnessed Fall Report (#392), dated 5/17/25 at 8:45 am, documents R1 was noted to be on the floor in R1's room. No injuries were noted. The intervention was to toilet after breakfast, monitor going into room to lie down and offer assistance to bed.R1's Un-witnessed Fall Report (#393), dated 5/17/25 at 8:15 am, documents R1 was found on the floor lying on right side at foot of the bed, with one slipper on right foot and one slipper on floor nearby. No injuries were noted. The intervention was staff to offer to assist R1 to bed if still up after 9:00 pm, allow R1 to stay up if R1 wishes to remain awake, assist with footwear and sit in visible area.R1's Un-witnessed Fall Report (#400), dated 5/21/25 at 6:15 pm, documents R1 attempted to transfer self from wheelchair into a chair in the television room and landed on buttocks. No injuries were noted. The intervention was to offer assistance into chair when R1 is in dining room.R1's Un-witnessed Fall Report (#406), dated 5/27/25 at 4:00 pm, documents R1 was at a table in the television room and R1 slid out of wheelchair landing on buttock and R1 denied hitting head. No injuries were noted. The intervention was to place non-skid pad in wheelchair.R1's Witnessed Fall Report (#434), dated 6/14/25 at 6:00 am, documents R1 was self-propelling in wheelchair and was noted to be seen on left side in front of wheelchair with left hand on mid-left forehead. R1 was wearing slippers and wheelchair was unlocked. R1 stated that R1 fell out of wheelchair onto head. R1 stated that R1 just wanted to stand up. One-on-one staff was present. No injuries were noted. Staff education was provided to observe R1 for attempts to stand from wheelchair and provide intervention.R1's Witnessed Fall Report (#370), dated 6/27/25 at 4:33 am, documents R1 was scooting toward front of wheelchair from trying to propel in wheelchair with buttocks. Staff unlocked wheelchair and was in process of repositioning R1 in the wheelchair at the same time R1 was moving forward and staff grabbed belt loop of pants and R1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145012 If continuation sheet Page 2 of 4 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 07/20/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some feel forward and landed on the floor on R1's right side. R1 was unable to give description of fall. No injuries were noted. The intervention was a medication review (Hydroxyzine) at bedtime to assist with sleeping, as R1 has been getting up around 2:00 am each morning. R1's Witnessed Fall Report (#448), dated 7/8/25 at 8:40 am, documents that staff was called to R1's room. R1 was observed on the floor in a sitting position and R1was unable to give a description of the fall. The root cause analysis documents that R1 was observed sitting on floor in room by wheelchair, with non-skid pad in place. R1 was unable to state what R1 was doing and that R1 frequently moves self to front of the wheelchair seat. No injuries were noted. The interventions were to lower the wheelchair seat. The Fall Report does not document that staff witnessed the fall. 2) R2's Minimum Data Set/MDS, dated [DATE], documents R2 requires partial to moderate staff assistance for sit-to-standing, chair-to- bed transfer and maximum staff assistance for sit-to-lying and lying-to-sitting, and that R1 requires moderate staff assistance to ambulate ten feet.The Facility Incident by Incidents Type Report, dated 4/1/25 through 7/17/25, does not document R2's falls on (4/3025, 5/25/25, 5/28/25 and 6/13/25).R2's current Care Plan documents: impaired cognitive loss (to person, place and time) related to Dementia and impaired vision. R2's fall interventions document: 4/12/25 intervention was to place fall mats next to bed; 4/26/25 intervention was to check orthostatic blood pressure every shift for three days; 4/30/25 frequent checks to offer toileting; 5/3/25 provide anti-rollback on wheelchair; 5/9/25 staff to check that wheelchair wheels are locked; 5/25/25 provide for frequent visual checks when R2 is in recliner; 5/28/25 review care plan and recliner moved to dining room/common area to provide for easier observation and flat call light in room; offer assistance to toilet for bowel movement at 6:00 am rounds and monitoring of bruise to forehead sustained during a fall on 6/13/25; 6/13/25 in R2's roomThe Facility could not produce R2's Neurological Evaluation Flow Sheets for R2's un-witnessed falls for 4/30/25, 5/25/25 and 6/13/25.R2's Un-witnessed Fall Report (#369), dated 4/20/25 at 9:30 pm, documents R2 attempted to self-transfer and rolled out of bed ono back on the floor mat next to bed. R2 was unable to recall events of the fall due to cognitive deficit. No injuries were noted. The intervention was to assist to the toilet frequently. The Facility did not document neurological evaluations.R2's Un-witnessed Fall Report (#371), dated 5/3/25 at 6:40 pm, documents R2 was observed sitting against the door frame in the sitting room during a self-transfer. No injuries were noted. The intervention was for anti-rollback device to be placed on wheelchair. The Facility did not document neurological evaluations. R2's Un-witnessed Fall Report (#405), dated 5/25/25 at 8:00 pm, documents R2 was calling for help and found to be laying on the floor on R2's back in the hallway outside of R2's room. R2 was unable to recall events of fall. No injuries were noted. R2 was re-educated to ask for help and placed on frequent visual checks when in recliner.R2's Un-witnessed Fall Report (#408), dated 5/28/25 at 1:30 pm, documents R2 was found on the R2's right side, on the floor of R2's room. R2 has a sign in room to ask for help and R2 stated, I was trying to get up and get a book and fell, I know I am not supposed to do that. The intervention was to place a sign in the room to ask for assistance and move recliner to common area. R2's Un-witnessed Fall Report (#419), dated 6/13/25 at 6:10 am, documents R2 was found on right side on the floor mat next to bed. Injury to the middle-left forehead with bump and bruise. The intervention was to offer assistance to toilet for bowel movement at 6:00 am. The Facility did not document neurological evaluations or evaluations of the bump or bruising.3) R3's Minimum Data Set/MDS, dated [DATE], documents R3 requires substantial to maximal staff assistance for sit-to-stand transfer, chair-to-bed transfer and to ambulate ten feet.The Facility Incidents by Incident Type Report, dated 4/1/25 through 7/17/25, documents falls for R3 (5/6/25 at 10:20 am, 5/16/25 at 3:15 pm, 6/22/25 at 2:10 am and 6/22/25 at 6:00 pm). The Report also documents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145012 If continuation sheet Page 3 of 4 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 07/20/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete bruises for R3 (5/9/25 at 8:30 am).R3's current Care Plan documents impaired cognitive loss (to person, place and time) related to Dementia and impaired hearing. R3's current Care Plan documents fall interventions on 5/6/25 for anti-rollback on wheelchair; 6/23/25 for fall mats at bedside; 6/24/25 for night light in room.R3's Un-witnessed Fall Report (#374), dated 5/6/25 at 10:36 am, documents R3 was noted scooting on buttocks on floor, scant blood noted to back of head. R3 was unable to recall events of fall. R3 sustained a laceration to the back of the head. The intervention was for anti-roll brake device to be applied to the wheelchair. The Facility could not provide documentation for monitoring of R3's head laceration.R3's Un-witnessed Fall Report (#427), dated 6/22/25 at 2:10 am, documents R3 was found on floor on buttocks against side of R3's bed. The intervention was to use a night light in the room to assist with reorientation and encourage to use call light to ask for assistance.R3's Un-witnessed Fall Report (#428), dated 6/22/25 at 6:00 pm, documents R3 was crying for help and was found lying on back on floor at doorway. R3 transferred self from bed and attempted to walk out of room by self. The intervention was to ask for assistance when ready to get up.R3's Un-witnessed Fall Report (#430), dated 6/23/25 at 1:50 pm, documents R3 was on R3's back on the floor in front of R3's bed. R3 was unable to recall the events of the fall. The intervention was to place a fall mat at R3's bedside.4) R4's Minimum Data Set/MDS, dated [DATE], documents R4 is independent with sit-to-stand transfer, chair-to- bed transfer and to ambulate ten feet.The Facility Incidents by Incident Type Report, dated 4/1/25 through 7/17/25, documents a fall for R4 (4/29/25 at 1:20 pm).R4's current Care Plan documents: impaired cognitive loss (to person, place and time) related to Dementia. The fall intervention for the 4/29/25 fall is to monitor whereabouts frequently.R4's Un-witnessed Fall Report (#366), dated 4/29/25 at 1:41 pm, documents R4 was observed on the floor in R4's room. The intervention was to redirect as needed. The Facility did not document neurological evaluations.R1's, R2's, R3's and R4's Fall Reports were not completed in their entirety.On 7/17/25 at 2:50 pm, V2 (Director of Nursing/DON) stated, I just started here in April of this year (4/2025). I am not sure where all the neurological documentation is for all the falls for (R1 R2, R3 and R4). Nursing should be doing the neurological checks for any un-witnessed fall and we keep them in a binder at the nurses station. When (R1) fell while receiving one-on-one monitoring, we had to educate the staff because (R1) should have been within arm's reach of the one-on-one staff and R1 should have not fallen. The staff left R1's presence to grab something. Some of the interventions such as education, reminders or signs may not be appropriate interventions because (R1, R2, R3 and R4) all have dementia and are cognitively impaired, so they would fall again, doing the same thing as before because they do not remember. I am trying to teach nursing to initiate appropriate and individual interventions for our Residents because some of these Residents' falls could have been prevented if the right intervention was in place. Event ID: Facility ID: 145012 If continuation sheet Page 4 of 4