Inspection·July 12, 2024

F 0584 f) Toilet #1 does not flush and the shower curtain was pulled off multiple shower hooks and falling down; Level of Harm - Minimal harm or potential for actual harm g) Toilet #2 does not have a privacy curtain; Residents Affected - Some e) Toilet #3 had poop sitting in it and the shower curtain was pulled off multiple shower hooks and falling down; f) A cabinet labeled towels and wash clothes contains broken pieces of PVC pipe (polyvinyl chloride/plastic plumbing), two shower curtain hangers, pieces of toilet paper and a gait belt. 6. On 7/11/24 at 10:00 AM, V6 (Maintenance Director) stated Corporate came in a few months ago and plans on doing a full remodel. It (bathroom) is hard to maintain because it is so old. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 2 of 12 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 07/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2. Current Physician Orders indicate orders for antifungal cream to R13's lower back, groin and sacrum twice daily and as needed. Residents Affected - Few On 7/9/24 at 2:00pm R13 noted with bright red, shiny area covering skin over entire buttocks, upper buttocks and lower buttocks and into groin. Also noted were various scattered satellite areas of redness surrounding solid red areas. On 7/9/24 at 11:15am and 1:45pm R13 was in bed on his back and both feet/heels were in contact with the vinyl mattress extender at the bottom of the mattress/footboard. At that time, it was noted that R13 had an oval brownish scabbed area right lateral foot and a circular dark brown scabbed are on left heel. V11, CNA (Certified Nurse Assistant) stated that R13's heels should be offloaded and placed a pillow under R13's lower lower legs. On 7/11/24 at 10:00am V8, LPN (Licensed Practical Nurse) assisted in assessment of R13's feet. R13 was noted to have an approximate 50-cent piece sized, dark brown/grey/deep purple scabbed area on left outer lateral heel and an oval brown/grey scabbed area on right outer lateral mid foot - directly over a bony prominence of R13's foot. V8, LPN stated that R13 has boots for his feet to keep his feet offloaded, however V8 did not find them in R13's room. V8 stated (R13) doesn't like to turn, has a lot of pain. He does like to lay more toward his right side. On 7/11/24 11:15am V3, ADON (Assistant Director of Nursing/Wound Nurse) stated I didn't know anything about the wounds on (R13's) feet. I'll check with Hospice. R13's care plan did not include a care plan or interventions for the fungal/reddened areas on R13's buttocks or for either of the wounds on R13's feet. On 7/12/24 at 12:20pm V2, DON (Director of Nursing) acknowledged there should have been care plans for R13's current skin conditions. Based on record review and interview, the facility failed to develop a skin care Plan of Care for one resident (R30); and failed to develop a foot wound Care Plan for one resident (R13), of 18 residents reviewed for Care Plans in a sample of 53. Findings includes: The facility's Comprehensive Care Plans Policy, Undated, 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. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS/Minimum Data Set assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 3 of 12 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 07/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. On 7/9/24 at 9:45 am, R30's bilateral upper extremities present with discoloration and lesions, with right upper arm more affected than left. R30 stated that the staff had not provided treatment or sleeve skin protectors to protect the skin on her arms. R30's Skin Monitoring: Comprehensive CNA/Certified Nursing Assistant Shower Sheet dated 7/2/24 indicated Discoloration at R30's bilateral forearms. R30's current Care Plan does not include focus, goals or interventions for care of R30's skin discoloration/lesions on R30's bilateral upper extremities. On 7/10/24 at 9:25 am, V3 Assistant Director of Nursing/ADON stated that (V15 Wound Physician) saw R30 this morning and stated that the reddish scar lesion on R30's right upper forearm was pre-cancerous, and will have a new treatment for that; stated that V15 said the discoloration on R30's upper extremities resulted from (R30's) Plavix medication. V3 ADON stated, We got the order for a sleeve for her forearms yesterday. At this same time, V1 Administrator and V3 ADON stated that R30's skin issues did not have to be on R30's Care Plan. V3 ADON stated that the discoloration on R30's bilateral upper extremities was nothing new for (R30), and that R30 has had the discoloration for a while. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 4 of 12 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 07/12/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, record reviews, and interview, the facility failed to ensure skin care concerns were addressed, failed to provide skin treatments, and failed to notify physician about skin concern for one resident (R30) of 18 residents reviewed for quality of care in a sample of 53. Residents Affected - Few Findings Include: Facility's Skin Assessment Policy, Undated, documents: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, daily for three days, and weekly thereafter. Consider the general status of the resident's skin. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Facility's Resident Rights Policy, Undated, documents: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The (State) Ombudsman Program Resident Rights for People in Long Term Care Facilities, Ombudsman Program, Revised 11/2018, documents: Your facility must provide services to keep your physical and mental health, at their highest practical levels. On 7/9/24 at 9:45am, noted that both upper extremities of R30 showed discoloration and lesions, with right upper arm more affected than left. R30 stated that the staff had not provided treatment or sleeve protectors to protect the skin on her arms. At this same time, R30 smiled and stated, No one beat me. I just don't like the appearance of how they look. R30's current Treatment Administration Record (TAR) dated 7/9/24 does not document skin treatments to R30's bilateral upper extremities; there were no physician orders for treatment of R30's bilateral upper extremities; and R30's current Care Plan does not provide focus, goals or interventions for care of R30's skin discoloration/lesions on bilateral upper extremities. R30's Weekly Skin Assessments (Dated 7/5/24, 6/28/24, 6/21/24, and 6/14/24) document: No issues noted/No skin issues. On 7/9/24 at 1:10pm, V13 Licensed Practical Nurse/LPN stated that she has observed the skin redness and discoloration on R30's bilateral upper extremities, and there had been no treatments. V13 LPN stated, I have done skin assessments for her; we have no treatment order, did not think to get protection sleeves for her to protect her skin. On 7/9/24 at 1:12pm, V14 Licensed Practical Nurse/LPN stated that Weekly Skin Assessments were done for R30. V14 LPN stated, (R30) has fragile skin. On 7/9/24 at 1:16pm,V3 Assistant Director of Nursing/ADON stated that she is the facility's Wound Care Nurse; stated that there was no treatment order for (R30's) bilateral upper extremities; and stated that (R30) would benefit from (arm skin protectors). V3 ADON stated, We will get an order for her arms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 5 of 12 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 07/12/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm R30's 7/10/24 Progress Note documents: Narrative: (R30) seen by (V15 Wound Physician) during rounds today. (V15) performed a pinch biopsy after reviewing risks with (R30) and (Power of Attorney/POA). On 7/10/24 at 10:05am, R30 stated that (V15 Wound Physician) saw her today and told her that that one reddish lesion on her right upper arm was cancerous. Residents Affected - Few R30's 7/10/24 Wound Evaluation and Management Summary, signed by V15 Wound Physician, documents: Diagnosis: Actinic Keratosis/AK's: Multiple AK's both arms with purpura resulting from anticoagulant usage with capillary fragility; using (arm skin protectors) to protect arms; however, expect she will continue to have purpura regardless but may not be as extensive with (arm skin protectors). (Internet definition of Actinic Keratosis/AK's: A rough, scaly, pink or white growth that occurs on the surface of the skin in areas (such as the face, neck, and back of the hands) frequently exposed to sunlight and that may develop into squamous cell carcinoma. Excessive exposure to sunlight causes skin cancer, but a pre-cancerous lesion called an actinic keratosis appears long before the cancer.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 6 of 12 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 07/12/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview, the facility failed to ensure the women's shower room was free from hazards. This failure potentially affects all sixteen female residents on the E-Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room. Findings include: 1. 07/09/24 01:55 PM, a 2-blade disposable razor was observed on the counter in the women's shower room which is utilized by the E Wing residents. 2. On 7/9/24 at 1:45 PM, V13 (Licensed Practical Nurse) stated That (disposable razor) should absolutely not be in here. The only way they (residents) even have access to them (disposable razors) are if staff give them (razors) to them (residents). They (razors) are kept locked up. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 7 of 12 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 07/12/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to provide physician orders for the administration of oxygen and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R13) of three residents reviewed for oxygen therapy in the sample of 53. Residents Affected - Few Findings include: Facility Policy/Oxygen Concentrator dated 2023 documents: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Oxygen is administered under the orders of the attending physician, except in case of an emergency. The nurse shall verify physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc). Facility Policy/Oxygen Administration dated 2024 documents: Oxygen is administered under orders of a physician, except in cases of an emergency. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. On 7/9/24, 7/10/24 and 7/11/24 R13 was in bed with an oxygen cannula administering oxygen at 3.5L (liters) during multiple observations on all three days. On 7/9/24 and 7/10/24 R13's oxygen tubing noted to be dated 6/30/24 and non-disposable humidification bottle not dated. On 7/11/24 at 9:30am V8, LPN (Licensed Practical Nurse) stated that oxygen tubing should be changed weekly along with non-disposable humidification bottles. On 7/11/24 at 10:12am V3, ADON (Assistant Director of Nursing) stated she was not aware R13 was receiving continuous oxygen and he should have a physician order. No physician order was found or presented indicating R13 should be receiving oxygen until 7/11/24 at 3pm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 8 of 12 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 07/12/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medication for one resident (R13) of five residents reviewed for unnecessary medications in the sample of 53. Findings include: Facility Policy/Use of Psychotropic Medication dated 2024: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Enduring Conditions (non-acute, chronic, prolonged): The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented. Current Physician Orders indicate order for Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to anxiety disorder and Major Depressive Disorder (date initiated 3/19/24). Physician Orders also indicate R13 is [AGE] years old, on Hospice Care with diagnoses that include Chronic Viral Hepatitis, Cirrhosis of Liver, Chronic Pain Syndrome and Emphysema. Current Care Plan/Pharmacotherapy: The resident (R13) uses psychotropic medications related to anxiety and depression dated 12/27/23. Care Plan does not indicate R13 receives an antipsychotic medication or target behaviors requiring the use of an antipsychotic medication. Behavior Monitoring and Tracking reviewed times three months (July, June, May/2024) with no behaviors identified. Psychiatric Evaluation dated 6/18/24 indicates No Audio/Visual hallucinations, delusions or Suicidal Ideation. Consent for Psychotropic Medications dated 3/19/24 indicates consent obtained for Seroquel 25mg on that date without documentation of diagnosis or indication for use. On 7/9/24, 7/10/24 and 7/11/24 R13 was seen in bed and able to answer questions appropriately. R13 did not display any inappropriate behaviors or signs/symptoms of psychosis. On 7/11/24 at 1:15pm V2, DON (Director of Nursing) stated she was unsure of the reason for R13 receiving Seroquel and redirected to the Psychiatric Evaluation dated 6/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 9 of 12 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 07/12/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure kitchen waste/trash was secured by leaving the lids left open on the trash receptacle located outside. This failure has the potential to affect all 90 residents residing in the facility. Residents Affected - Many FINDINGS INCLUDE: The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility. The facility policy, entitled Disposal of Garbage and Refuse, not dated, document: Policy: The facility shall properly dispose of kitchen garbage and refuse. 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. On 7/9/2024, at 9:00 a.m., during the initial kitchen tour, with V7/Head Cook, the outside trash dumpster/receptacle lids were observed to be left open. On 7/9/2024, at 9:00 a.m., V7 confirmed the lids to the trash dumpster should be closed to keep animals from getting into the trash. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 10 of 12 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 07/12/2024 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure affects fourteen residents (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R832,R84 and R85) in the total sample of 53. . Findings Include: On 7/10/24 at 9:00 AM V6 (Maintenance Director) confirmed that the facility does have some rooms that do not meet the 80 square foot per resident requirement. l On 7/11/24 (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R83,R84 and R85) were noted to occupy the rooms identified as less than 80 square feet per resident according to the facility floor plan. A letter signed by V9 (Previous Administrator) dated 1/29/2019 indicates that the facility has submitted a waiver to the State Agency regarding the square footage of their resident rooms as they are slightly under 80 square foot per resident requirement. On 7/12/24 at 10:30AM V1 (Administrator) stated that waiver dated 1/29/2019 was the last waiver sent in to the State Agency as far as he was aware. A letter from the State Agency sent to the facility and dated 4/3/2019 indicated that rooms A1, A4, A8, B1, B3, B7, D5, and D10 were waivered for not providing at least 80 square feet per bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 11 of 12 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 07/12/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food service areas and equipment was free of pests/insects, in that gnats were observed on and flying around the juice dispenser spigot/handle located in the facility kitchen. This failure has the potential to affect all 90 residents residing in the facility. Residents Affected - Many FINDINGS INCLUDE: The Centers for Medicare & Medicaid Service/CMS Form 671, entitled Long Term Care Facility Application for Medicare and Medicaid, dated 7/9/2024, document 90 residents reside in the facility. The facility policy, entitled Sanitation Inspection, not dated, document: Policy Explanation and Compliance Guidelines: 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. On 07/9/2024, at 8:50 a.m., during the initial kitchen tour, with V7/Head Cook, the juice dispenser spigot/handle was observed to have gnats flying around and on the dispensing end. On 7/9/2024, at 8:50 a.m., V7 confirmed the gnats were present and they shouldn't be present as the facility has attempted to exterminate them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 12 of 12