Inspection·May 17, 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 interview and record review the facility failed to revise care plans for three residents (R1, R3, R4) who smoke of three residents reviewed for care plan revision. Residents Affected - Few Findings include: Facility Policy/Comprehensive Care Plans dated 2023 documents: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. On 5/14/24 at 2:30pm V2, DON (Director of Nursing) stated R1, R3 and R4 have all had their smoking privileges taken away due to repeatedly breaking the smoking rules. On 5/16/24 at 3:00pm V2, DON stated that R1's smoking privileges have been revoked since 12/5/23. NP (Nurse Practitioner) note dated 5/7/24 indicates R1 has lost all smoking privileges due to not following facility smoking rules. On 5/14/24 V1, Administrator and V2, DON (Director of Nursing) stated that R1 continues to obtain contraband, possibly smoking in the bathroom and receiving smoking materials from other residents. On 5/14/24 R1 stated that she's in trouble for having a vape and has been banned from cigarettes since then. R1 stated I have broken the rules since then. R1 identified R3 and R4 as also breaking the smoking rules and having their smoking privileges revoked. Current Care Plan indicates: Due to symptoms of Serious Mental Illness R1 can be an unreliable reporter. R1 may indicate she does not remember information communicated to her and may make statements that are not based in reality. R1 is a smoker and have expressed that she does not have funds to purchase smoking materials. R1 was provided smoking cessation materials and provided nicotine gum. R1 did not follow smoking policy and was observed smoking while also using nicotine gum. R1 was educated on the risks of using smoking cessation and expectation was told to R1 to either use smoking cessation or smoke but not both. Smoking cessation resumed on 11/3/22. R1's care plan does not include revocation of smoking privileges. 2) On 5/14/24 R3 stated he is currently on smoking restriction because he gave cigarettes to R1 (who is also on restriction). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 2 of 3 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 145987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Galesburg 1145 Frank 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 0657 On 5/16/24 at 3:00pm V2, DON stated that R3's smoking privileges have been revoked since 4/8/24. Level of Harm - Minimal harm or potential for actual harm NP Note dated 4/17/24 R3 lost walking day pass and smoking privileges due to not following rules-Ordered gum for smoking cessation. Residents Affected - Few R3's care plan indicates R3 is a smoker and requires supervised smoking. R3's care plan does not address non-compliance with smoking rules, specific incidence of non-compliance, revised interventions or current revocation of smoking privileges. 3) Progress Note Text dated 5/2/24 indicates: at last smoke break R4 was noted to be outside taking drags off of other resident cigarettes; R4 was educated and brought back inside the facility. On 5/16/24 at 3:00pm V2, DON stated that R4's smoking privileges have been revoked since 4/15/24. R4's care plan indicates R4 is a smoker and is able to carry smoking materials into the community and keep smoking materials in a secured location. R4's care plan does not address non-compliance with smoking rules, specific incidence of non-compliance, revised interventions or current revocation of smoking privileges. On 5/16/24 at 310pm V2, DON stated the Social Service Director was responsible for revising the smoking care plans. They just didn't get done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 3 of 3