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
prior to working their next shift including agency nurses.
Sign-in sheets were utilized.5. On 9/10/25,
jeopardy to resident health or residents was completed by V11 and continued.6. V8 verified the facility's contracted pharmacy safety 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
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
145987 09/11/2025
Allure of Galesburg 1145 Frank Street Galesburg, IL 61401
Based on observation, interview, and record review, the facility failed to ensure nurses do not
(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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.