Allure Of Galesburg

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

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Printed: 04/13/2026 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

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 (Resident R5-Resident 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 (Resident R8, Resident R12, Resident R13, Resident R14, Resident 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 Resident R6, Resident R7, and Resident R8-Resident 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 Resident R15-Resident 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: Resident R8-Clonazepam 0.5 mg, Resident R12-Ativan 0.5 mg, Resident R13 Tylenol with Codeine 300/30 mg, Resident R14-Ativan 1 mg, and Resident 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.

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