Inspection·November 13, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An abuse investigation dated 10/25/24 documents that R2 smacked R5 (her room mate at the time). The investigation documented that R2's bed had just been (that day) moved from the bed by the door to the bed by the window. R2's new room mate was attempting to transfer herself into bed and R2 forgot about the bed change and thought that R5 was getting into R2's bed so she smacked her to stop her. The investigation documents that R2 was apologetic immediately after she smacked R5 because she (R2) had forgotten that that was not her bed now. On 11/13/24 at 10:00 AM R2 stated They (facility staff) know not to give me room mates, it never turns out well. R2 confirmed she smacked R5 and stated well, I thought she was trying to get in my bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 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 145987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview the facility failed to maintain accurate clinical records for four (R1,R2,R3 and R4) of five residents reviewed for medical record accuracy. Residents Affected - Few Findings Include: The Facility's undated Documentation in Medical Record policy documents Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident;s progress through complete, accurate and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. An abuse investigation dated 10/18/24 documents that R1 and R2 were witnessed by staff to be having a verbal disagreement in the main dining room. R1 was over heard telling R2 loudly to get away from him. R1 was seen pushing a chair between himself and R2 to provide distance between them and R2 leaned across and smacked R1 across the face, dislodging his glasses from his face causing a 1/2 cm (centimeter) by 1/2 centimeter scratch above his right eye which was treated with first aid. Neither R1 nor R2's medical record include any documentation of R2 smacking R1 across the face. On 11/12/24 at 2:00 PM V2 (Licensed Practical Nurse/Assistant Director of Nursing) confirmed that neither R1 nor R2's medical record contained any documentation regarding R2 smacking R1 across his face. V2 stated It should be documented and it is not. It is documented in the Risk Assessment part of R2's medical record which is not accessible to everyone. V2 stated that the Risk Assessment part of the medical record is available only to managers in the facility and/or corporation. An abuse investigation dated 10/17/24 documents that R3 and R4 went on a home visit together from 9/28/24 until 10/09/24. During a counseling session on 10/17/24 R3 spoke to the counselor about inappropriate sexual behavior by R4 during that visit and R3's counselor reported that to V1 (Administrator) of the facility. The abuse investigation documents that the local police department was notified and came to the facility and took a statement from both R3 and R4. The abuse investigation documents that R4 was put on 1:1 supervision immediately on 10/17/24 at an unknown time. On 11/13/24 at 9:30 AM R3 reported that after the investigation started on 10/17/24 that R4 was put on 1:1 supervision with a staff member. R3 reported that V8 (Police Officer) came to the facility and interviewed her and she chose to not press charges. On 11/13/24 V4 (Certified Nurse Aid), V5 (Certified Nurse Aid), V6 (Certified Nurse Aid) and V7 (Licensed Practical Nurse) all confirmed that R4 was on 1:1 supervision from 10/17/24 until they received a text that it was canceled. The facility's CNA schedule documents a 1:1 staff member designated to be with R4 starting on 2nd shift on 10/17/24 and crossed out on 10/25/24 starting on 2nd shift. V2 (Licensed Practical Nurse/Assistant Director of Nursing) provided a screen shot of a group text (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 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 145987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few message from V9 (Licensed Practical Nurse/ Previous Care Plan Coordinator) that indicated on 10/25/24 at 11:09 AM that documented All 1:1 that were scheduled are now canceled, if you were scheduled disregard. regarding R4. On 11/13/24 at 12:05 PM V1 (Administrator) stated that the Interdisciplinary Team met on 10/25/24 and discussed the fact that R4 had not made any aggressive moves towards R3 or any other residents or staff members and rarely left his room. V1 stated that interviews with other female residents showed that no other residents had any concerns with R4 so it was decided to take him off the 1:1 supervision. V1 confirmed that none of that meeting was documented. Neither R3 nor R4's medical record contained any information regarding the allegation, when the intervention of 1:1 supervision was started or stopped or how the decision to stop the 1:1 supervision was made and by whom. On 11/13/24 at 1:30 PM V2 (Licensed Practical Nurse/Assistant Director of Nursing) confirmed that there was no documentation of the allegation of sexual misconduct of R5 to R4 and the subsequent investigation, interventions and conclusions were documented in R3 or R4's medical record and it should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145987 If continuation sheet Page 4 of 4