Allure Of Galesburg
ALLURE OF GALESBURG in GALESBURG, IL — inspection on September 11, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Allure of Galesburg
1145 Frank Street Galesburg, IL 61401
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: