Inspection·July 18, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise a care plan with a change in transfer status for one of one resident (R49) reviewed for Activities of Daily Living in a sample of 31. Residents Affected - Few Findings include: The Facility's Care plan revisions upon Status Change policy, dated 4/3/23, documents The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Upon identification of change in status, the nurse will notify the MDS (Minimum Data Set) Coordinator, the physician, and the resident representative, if applicable. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect the current resident needs. R49's Physician orders, dated 7/16/24, document an order signed 6/27/24 to be right foot toe touch weight bearing. On 7/15/24 at 9:30 AM, R49 was sitting in manual wheelchair with a mechanical lift sling underneath of him. On 7/16/24 at 11:25 AM, R49 stated he is being transferred with a mechanical lift now because every time he puts weight on his right foot his heel bleeds through the dressing. R49 states, The very first time staff tried to do toe touch weight bearing, I put weight on my heel because I felt I was going to lose my balance. R49 further states, Staff attempted three times and each time I had difficulty. I am able to put weight on my left leg. The last time staff had me standing I was in a special shoe and my wound bled but not as much. The staff and I get scared. So, we stopped trying because we don't want it to bleed. I stood for a bit about a month ago and I felt more stable then, but the staff stopped attempting after because I was scared. R49's care plan, dated 7/16/24, documents R49's transfer status is one person assist with a slide board. R49's care plan has no documentation of a revision of his change in transfer status. On 07/17/24 10:44 AM, V10 (Certified Nursing Assistant) and V9 (Licensed Practical Nurse) transferred R49 with mechanical lift from his bed to his wheelchair. A transfer slide board was sitting on top of a bedside table in R49s room. On 7/17/24 at 9:55 AM, V7 (Director of Rehab) stated on 6/28/24 upon discharge from therapy R49 was one assist with slide board. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145619 If continuation sheet Page 2 of 5 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 145619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Lake Storey 1250 West Carl Sandburg Drive 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 0657 On 7/17/24 at 10:30 AM, V4 (MDS Coordinator) verified that R49's care plan was not revised following his change in transfer status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145619 If continuation sheet Page 3 of 5 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 145619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Lake Storey 1250 West Carl Sandburg Drive 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter was cleansed with a cleaning agent indicated for indwelling urinary catheter care for one of two residents (R31) reviewed for indwelling urinary catheters in the sample of 31. Findings include: The facility's Catheter care policy (revised 02/05/24) documents the following: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. This policy also documents, Male: Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). R31's current medical record documents R1's current diagnoses to include: Malignant Neoplasm of Prostate, Benign Prostate Hyperplasia, Obstructive and Reflux Uropathy, and Urinary Tract Infection. On 07/15/24 at 11:00 AM, R31 was sitting in a wheelchair near his bed watching television. An indwelling urinary catheter bag containing clear yellow urine was hanging on the lower aspect of R31's wheelchair, and R31 stated he has a history of urinary tract infections. On 07/17/24 at 09:35 AM, R31 was lying supine in bed watching television. An indwelling urinary catheter drainage bag containing clear, yellow urine was secured to the lower aspect of R31's bed. V3 (Registered Nurse) entered R31's room at this time to provide indwelling urinary catheter care. V3 assisted R31 to pull his pants and incontinence brief down, and an indwelling urinary catheter was in place and secured to R31's left leg with a securement device. V3 proceeded to clean R31's indwelling urinary catheter with several wipes obtained from a resealable package of disinfecting wipes. Once care was completed, V3 assisted R31 to pull up his pants and incontinence brief. V3 stated disinfecting wipes are what she utilizes to clean all indwelling urinary catheters. On 07/17/24 at 10:00 AM, V3 provided the package of disinfecting wipes, and the following active ingredients were documented on the packaging: Octyl decyl dimethyl ammonium chloride; Dioctyl dimethyl ammonium chloride; Didactyl dimethyl ammonium chloride; and Alkyl dimethyl benzyl ammonium chloride. The packaging label also documents the following: Do not use as a baby wipe or for personal cleansing. This is not a baby wipe! V3 then stated, I screwed up, and confirmed she should not have utilized the disinfecting wipes to provide R31's indwelling urinary catheter care. On 07/17/24 at 11:20 AM, V2 (Director of Nursing) stated that V3 should not have used disinfecting wipes to cleanse R31's indwelling urinary catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145619 If continuation sheet Page 4 of 5 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 145619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Lake Storey 1250 West Carl Sandburg Drive 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 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to serve a physician ordered dietary supplement for one of four residents (R50) reviewed for weight loss in the sample of 31. Residents Affected - Few Findings include: The facility's Nutritional and Dietary Supplement policy, dated 4/9/24, documents, It is the policy of this facility that nutritional and dietary supplements will be used to compliment a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practical level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs. R50's physician order dated 7/18/24 documents R50 has an order to receive gelato (supplement) twice a day at lunch and dinner dated 3/15/24. R50's dietary note, dated 7/10/24 at 1:57 PM, documents, (R50) discussed with IDT (Interdisciplinary Team) during Nutrition-At-Risk (NAR) meeting related to wound monitoring. R50s dietary note also documents that R50 receives fortified ice cream twice a day. On 7/16/24 at 12:23 PM, R50 was sitting at the dining room table with her lunch. R50's tray did not include the physician ordered gelato supplement. On 7/16/24 at 12:31 PM, V15 (Certified Nursing Assistant) began helping R50 with her meal. R50's meal card that was lying on the table documented that gelato should have been served with R50's lunch. V15 stated that R50 was not served gelato with her lunch meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145619 If continuation sheet Page 5 of 5