Inspection·September 11, 2025

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg. R4's EMR progress notes document: 8/15/25, at 7:15 AM, this nurse [V4] was notified by resident [R5] that he saw the third shift B/E Hall nurse [V3] give his 5 AM medications to this resident. Resident stated he felt unwell this a.m. Resident laying bed and vitals checked, and resident noted to be hard to arouse and lethargic. [V8/medical doctor], 911, Local hospital], and brother notified.On 9/9/25, at 1:25 p.m., V2/Director of Nursing confirmed: On 8/15/25, V3 (3rd Shift Nurse) pre-popped [pre-prepared] and stacked residents' medications. R4 was subsequently administered R5's medications-Ascorbic Acid 500 milligram/mg, Aspirin 81 mg, Claritin 10 mg, Clopidogrel 75 mg, Fluoxetine 60 mg, Multivitamin, Seroquel 100 mg, Vitamin D3 125 ug (micrograms), Lyrica 300 mg, Klonopin 1 mg, ibuprofen 600 mg, Robaxin 750 mg; After realizing the error, V3 then administered R4's correct medication which included-diazepam 5 mg, carbidopa/levodopa 25/100 2 tabs; V3 did not report the error; V4/Licensed Practical Nurse/LPN 1st shift nurse administered R4's 7:00 a.m. medications-Lexapro 10 mg Celebrex 200 mg Protonix 40 mg, Keppra 1500 mg, Metoprolol 50 mg, Morphine Sulfate Extended Release 15 mg, Carbidopa/Levodopa 25/100 2 tabs, Entacapone 200 mg, and Lacosamide 100 mg; R5 then told V4 that V3 had given his medications to R4; and R4 was sent to the emergency room where R4 was admitted .R4's hospital documentation: 8/15/25 Emergency Room-Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: CNS [Central Nervous System] failure or compromise, metabolic crisis and respiratory failure; Hospital admission History & Physical-Admitting diagnosis: Medication overdose; and Discharge Summary, dated 8/18/25, document: [R4] was admitted after unintentional medication overdose given at facility. Patient noted to be lethargic, upon arrival is also bradycardic into 40s. Patient given Narcan x3 in ED and was protecting his airway and brought to ICU [Intensive Care Unit]. ICU attending when rounding on the patient noted that he had gone apneic and was difficult to arouse and patient was then intubated. He was extubated the following day and did well. He was started on a diet and his home medications and was at his baseline mental status.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and found V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups on and in their medicine carts. Among the medicines, pre-popped, five resident med cups contained controlled medicines which were signed out on the narcotic log. V5 and V6 confirmed they should not have pre-prepared/stacked medicine cups.On 9/10/25, at 4:15 a.m., R4 stated, The facility tries to make me feel better by telling me that the nurse is no longer working, but it doesn't make me feel better. If [R5] didn't tell them [facility staff] I got the wrong medicine, I would be dead.On 9/10/25, at 1:55 p.m., V8/Regional Nurse confirmed the medication error should have been immediately reported and all medications held pending the medical doctor's approval.On 9/10/25, at 3:25 p.m., R5 confirmed he saw the nurse give his medicine, with pudding, to R4. He did not know that those were R5's meds at the time. Then the nurse, realizing her mistake, took the empty med cup which had R5's name written on it and said to R5, I suppose this is you? When R5 said, yes, she popped his meds out again and gave them to him. R5 went to the dayshift nurse [V4] and asked her if his meds were double punched, and when she said, yes, he told V4 that his meds had been given to R4.The Immediate Jeopardy began on 8/15/25, at 4:24 a.m., when V3 administered the wrong pre-prepared medications to R4. V1/Administrator was notified of the Immediate Jeopardy on 9/10/25, at 3:09 p.m.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. R4's medical record confirms R4 was sent immediately to the emergency room, on 8/15/25, for treatment of lethargy and low blood pressure and remained in the hospital until 8/18/25.2. On 8/18/25, V3's employment, with the facility, was terminated and the incident reported to the State Nursing Board.3. On 9/10/25, (continued on next page) 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 09/11/2025 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, reviewed all procedures, review investigation, review root cause analysis, review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.4. On 9/10/25, V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.5. On 9/10/25, an audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.6. V8 verified the facility's contracted pharmacy service performed a med cart audit and medication administration audit on 9/10/25.7. The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.8. The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines. 9. On 9/11/25, Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.10. On 9/11/25, V12/LPN, V13/LPN, and V14/LPN, confirmed they had received education on proper medication preparation and administration procedures on 9/10/25.11. On 9/11/25, Medication Cart Audit was completed by [and observed by the State Agency] V12, V13, and V14's med carts. No concerns.Completion date 9/10/2025 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 09/11/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure nurses do not pre-prepare and stack clear medication cups (with meds) in/on medicine carts for 16 residents (R5-R21) of 16 residents reviewed for medications not being pre-prepared, in a total sample of 21. FINDINGS INCLUDE:Facility Policy, entitled Medication Storage, copyright 2025, document: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls; b. Only authorized personnel will have access to the keys to locked compartments; and c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.On 9/10/25, at 4:00 a.m., the State Agency entered the facility and observed V5/Registered Nurse and V6/LPN had pre-prepared and stacked medicine cups, with resident medication, on and in their medicine carts. Among the medicines, pre-prepared, five resident med cups (R8, R12, R13, R14, R15), along with non-controlled medication, contained controlled medicines which were signed out on the Controlled Drug Received/Record/Disposition Form.On 9/10/25, at 4:00 a.m., V5/Registered Nurse confirmed V5 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication, on top of the medicine cart for R6, R7, and R8-R14. Additionally, V5 stated, I am forced to do that here because the type of residents who get mad when they are not ready and it takes time to pop them out one at a time.On 9/10/25, at 4:05 a.m., V6 confirmed V6 should not have pre-prepared and stacked the clear med cups, containing residents' morning medication for R15-R21, in the top drawer of the medicine cart.The individual medicine carts, Controlled Drug Received/Record/Disposition Form document the following controlled medicine was signed out, as morning medication, by V5 and V6: R8-Clonazepam 0.5 mg, R12-Ativan 0.5 mg, R13 Tylenol with Codeine 300/30 mg, R14-Ativan 1 mg, and R15-Ativan 1 mg.On 9/10/25, V1/Administrator confirmed V5 and V6 should not have pre-prepared resident medication, and they won't be back. Event ID: Facility ID: 145987 If continuation sheet Page 4 of 4