Allure of Galesburg

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adequate supervision and reassess elopement risk status to prevent a resident with known cognitive impairment, and with a known attempt of exiting the building unauthorized, from eloping from the facility for one of three residents (R1) reviewed for elopement in the sample of three. Specifically, the facility failed to adequately supervise (R1) with a known diagnoses of Bipolar and with cognitive impairment, who was documented at risk for elopement and a history of unauthorized exit attempts. The facility also failed to respond to and investigate sounding door alarms at secured facility exits and conduct a missing resident sweep/headcount when exit alarms were triggered. [...]

Inspectors wroteBased on Interview and Record Review, the facility failed to implement its abuse policy when an allegation of staff-to-resident sexual abuse was received for one of four residents (R2) reviewed for abuse in the sample of four. Findings Include:The facility's Abuse, Neglect, and Exploitation policy dated 1/30/2026 documents, Policy explanation and compliance guidelines, 1. The facility will develop and implement a written procedure that: c. includes training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide significant medications for High Blood Pressure, Depression, Anxiety, High Cholesterol, and Bipolar Schizoaffective Disorder for one (R3) of three residents reviewed for medications in a sample of seven. These failures resulted in R3 having an increase in blood pressure of 198/101 where he was dizzy and had headaches, and an increase in his anxiety which resulted in R3 getting an increase in his dosage of Hydroxyzine from twice a day to three times a day for his anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to prevent physical abuse from happening for four (R1, R2, R4, and R5) of four residents reviewed for abuse in a sample of seven. The abuse altercation on 3/1/26 between R1 and R2 resulted in R1 going to the hospital to be evaluated for injuries. The abuse altercation between R1 and R5 resulted in R5 going to the hospital to be evaluated due to neck pain after being hit in the back of his head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in their original packaging and failed to destroy medications according to their policy for one (R1) of three residents reviewed for medications in a sample of seven.

Inspectors wroteBased on interview, and record review, the facility failed to have accurate medical records regarding a therapeutic leave, medications, and a physical altercation for two (R1 and R2) of seven residents reviewed for accurate medical records in a sample of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure emergency medical equipment was present, functional, routinely checked and available for use during a medical emergency, for one of three residents (RI), reviewed for emergency response. The facility also failed to ensure nursing staff were trained and competent in the contents and operation of emergency equipment. These failures resulted in staff being unable to provide timely life- saving interventions to R1, who suffered an unplanned medical emergency and died. The deficient practice placed all facility residents at risk for delayed or ineffective emergency response. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident unplanned death was investigated and reported to the state agency, within the required time frame. This failure has the potential to affect all 84 residents currently residing in the facility. R1's electronic medical record documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Frontotemporal Neurocognitive Disorder, Major Depressive Disorder, Dysphasia, Chronic Obstructive Pulmonary Disease, Anxiety Disorder and Diabetes Mellitus. R1's Advance Directives form, dated [DATE] documents that R1 was a Full Code. R1's Nursing Progress Notes, dated [DATE] and signed by V3/Registered Nurse documents, (R1) observed to have had a small emesis so nurse helped (R1) to get cleaned up and cleared mouth and neck from emesis. (R1) was then sat up and verbalized feeling okay. [...]

Inspectors wroteBased on record review and interview the facility failed to protect a resident from staff-to-resident sexual abuse, failed to assess a resident's ability to consent to sexual activity, and failed to protect residents from staff-to-resident verbal abuse for three of seven residents (R2, R3, and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3 in June 2025, V7 continuing to have sexually inappropriate conversations and video nudity by electronic communication with R3, and V7 sexually assaulting R3 on at least three occasions while R3 was attending church services. [...]

Inspectors wroteBased on record review and interview the facility failed to report allegations of staff-to-resident sexual abuse and exploitation, allegations of resident-to-resident physical abuse, and allegations of staff-to-resident verbal abuse immediately to the State Agency, Local Police, and Administrator once the facility was made aware for two of seven residents (R3 and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) continuing to have non-consensual sex with R3, V7 continuing to sexually exploit R3 by electronic communications, and V7 verbally abusing R6 on multiple occasions once R6 witnessed R3 and V7 engaging in inappropriate conversations and video nudity by electronic communications. [...]

Inspectors wroteBased on record review and interview the facility failed to protect residents from staff-to-resident sexual abuse and verbal abuse, failed to develop and implement interventions to increase safety and adequately supervise the residents, failed to immediately initiate and investigation of allegations of staff to resident sexual and verbal abuse, and failed to submit a final investigation report of allegations of staff-to-resident sexual and verbal abuse to the State Agency within five working days for two of seven residents (R3 and R6) reviewed for abuse in the sample of seven. These failures resulted in V7 (Prior Dietary Aide) having continual access to R3 after V7 was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with R3 in June 2025 and V7 continuing to sexually exploit R3 and have non-consensual sexual relations with R3. [...]

Inspectors wroteBased on record review and interview the facility failed to prevent misappropriation of a resident's controlled-substance medication for one of three residents (R8) reviewed for misappropriation of medications in the sample of seven.

Inspectors wroteBased on record review and interview the facility failed to properly store and account for a resident's controlled-substance medication for one of three residents (R8) reviewed for medication storage in the sample of seven.

Inspectors wroteBased on record review and interview the facility failed to properly prepare and administer medications to prevent a significant medication error for one resident (R4) of three residents (R3, R4, and R5), reviewed for medication administration errors in a total sample of 21. These failures resulted in R4 receiving the wrong medication and being hospitalized for lethargy, heart rate in 40s, difficult to arouse, and subsequently being intubated. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/10/25, the facility remains out of compliance at severity level 2 while the facility continues to educate the nursing staff on proper medication preparation and administration and conduct audits to ensure continued compliance.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 91 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority to reevaluate residents when the Preadmission Screening and Resident Review (PASRR) approval had ended for six of 26 residents (R26, R41, R79, R81, R87, R498) reviewed for PASRR compliance in a sample of 42 residents.

Inspectors wroteB. Findings include: Facility Fall Prevention Program, dated 2024, documents: each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls; the nurse will indicate on the Resident's fall risk and initiate interventions on the Resident's base line care plan, accordance with the Resident's level of risk; each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care; and interventions will be monitored for effectiveness and the plan of care revised as needed. 1. R24's Fall Report (#410), dated 12/22/24, document a fall in R24's bathroom hitting head on tub. The Report or R24's Care Plan does not document fall interventions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe handling of oxygen humidification vessels and change oxygen supplies (oxygen tubing and humidification bottles) for four of four residents (R15, R23, R24 and R37) reviewed for oxygen therapy in a sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to ensure Influenza and Pneumococcal immunizations were offered to four of five residents (R26, R87, R81, R498) reviewed for immunization compliance in a sample of 42.

Inspectors wroteBased on interview and record review the facility failed to assess two residents (R12 and R87) for available walking pass privileges of 24 residents reviewed for choices in a total sample of 42.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R26) was free from verbal abuse of two residents reviewed for abuse in a total sample of 42. Findings Include: The Abuse, Neglect, and Exploitation policy dated 2/3/25 documents It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. [...]

Inspectors wrote2. R13's Physicians Orders include the following orders: Cleanse wound to sacrum with normal saline, pat dry and apply hydrocolloid (TTHSA) every day shift, every Tuesday, Thursday and Saturday for pressure wound. R13's physicians Orders also the following wound care: Cleanse open area to right hip with normal saline, pat dry and apply a border form (bordered dressing) until healed one time a day for opening to old incision. R13's current TAR/Treatment Administration Record includes the task to implement EBP/Enhanced Barrier Precautions every shift. On 7/1/25 at 11:00am there were no gowns in or outside of R13's room for facility staff to utilize and no signage indicating Enhanced Barrier Precautions were in place. On 7/1/25 at 11:30am V13 LPN/Licensed Practical Nurse, V21 and V22 CNAs/Certified Nurse's Assistant entered R13's room to perform R13's wound cares. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure their nurse staffing information was posted and accessible to residents and visitors. This has the potential to affect all 91 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent resident to resident physical abuse for one resident (R4) of four residents reviewed for abuse in the sample of four.

Inspectors wroteBased on record review and interview the facility failed to prevent staff to resident sexual abuse and mental abuse for one of three residents (R1) reviewed for abuse in the sample of four. These findings resulted in R1 being subjected to bribery with alcohol and drugs and sexual abuse by V3 (CNA/Certified Nursing Assistant) on more than 100 occasions, R1 suffering fear and depression, and R1 requiring prophylaxis for prevention of STDs (Sexually Transmitted Diseases). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 6-1-24 when V3 started bribing R1 with alcohol and drugs and started sexual abusing R1 within the facility. V1 (Administrator), V15 (Regional Director of Operations), V17 (Corporate Nurse) were notified of the Immediate Jeopardy on 2-3-25 at 11:00 AM. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 93 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to implement their Abuse Policy to immediately report an allegation of staff-to-resident sexual abuse to the State Agency for one of three residents (R1) reviewed for Abuse in the sample of four.

Inspectors wroteBased on record review and interview the facility failed to ensure two of five residents (R1 and R5) were free from physical abuse. Findings Include: The Facility's undated Abuse, Neglect and Exploitation policy documents it is the policy of facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation resident property. The policy documents Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. [...]

Inspectors wroteBased 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. 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen waste/trash was secured by leaving the lids left open on the trash receptacle located outside. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food service areas and equipment was free of pests/insects, in that gnats were observed on and flying around the juice dispenser spigot/handle located in the facility kitchen. This failure has the potential to affect all 90 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the women's shower room was clean, functional and protected the resident's privacy. This failure potentially affects all sixteen females residing on the E Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room.

Inspectors wroteBased on observation and interview, the facility failed to ensure the women's shower room was free from hazards. This failure potentially affects all sixteen female residents on the E-Wing (R3, R5, R9, R11, R16, R22, R27, R33, R54, R50, R55, R58, R70, R78, R90, R394) that utilize the women's shower room.

Inspectors wroteBased on record review and interview, the facility failed to develop a skin care Plan of Care for one resident (R30); and failed to develop a foot wound Care Plan for one resident (R13), of 18 residents reviewed for Care Plans in a sample of 53.

Inspectors wroteBased on observation, record reviews, and interview, the facility failed to ensure skin care concerns were addressed, failed to provide skin treatments, and failed to notify physician about skin concern for one resident (R30) of 18 residents reviewed for quality of care in a sample of 53. Findings Include: Facility's Skin Assessment Policy, Undated, documents: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission, daily for three days, and weekly thereafter. Consider the general status of the resident's skin. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. Facility's Resident Rights Policy, Undated, documents: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide physician orders for the administration of oxygen and failed to change oxygen tubing/humidifier bottles per facility policy for one resident (R13) of three residents reviewed for oxygen therapy in the sample of 53.

Inspectors wroteBased on observation, interview and record review the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medication for one resident (R13) of five residents reviewed for unnecessary medications in the sample of 53.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure greater than 80 square feet per resident in multiple resident rooms. This failure affects fourteen residents (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R832,R84 and R85) in the total sample of 53. . Findings Include: On 7/10/24 at 9:00 AM V6 (Maintenance Director) confirmed that the facility does have some rooms that do not meet the 80 square foot per resident requirement. l On 7/11/24 (R2,R17,R21,R28,R31,R44,R48,R53,R56,R68,R72,R83,R84 and R85) were noted to occupy the rooms identified as less than 80 square feet per resident according to the facility floor plan. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two residents (R1 and R3) was free from verbal abuse by an employee of three resident reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to revise care plans for three residents (R1, R3, R4) who smoke of three residents reviewed for care plan revision.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent staff verbal abuse for one (R1) and failed to prevent resident-to-resident physical abuse for two of two (R5 and R6) residents reviewed for abuse in the sample of three.

Inspectors wroteBased on record review and interview the facility failed to prevent abuse for two of five residents (R1 and R5) reviewed for abuse in the sample of five .

Inspectors wroteBased on interview and record review the facility failed to prevent mistreatment and verbal abuse of one resident (R2) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to immediately report an allegation of verbal abuse to the Abuse Coordinator for one resident (R2) of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident to resident physical abuse for two of three residents (R1, R2) reviewed for abuse in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN) for eight hours in a 24-hour period. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: The facility's nursing schedule dated 3/9/23 through 4/5/23 does not have an RN scheduled for eight hours a day on 3/22/23 and 3/25/23. 4/12/23 1:04 PM, V2, Director of Nursing (DON), verified there was no RN coverage for 3/22 and 3/25 and stated, That would be correct, we had an issue of not having enough RN's to cover all the days. Facility census report provided by V3, Minimum Data Set (MDS) Coordinator, dated 4/11/23 documents 94 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance reviews and education based on the performance review of the Certified Nursing Assistants (CNA) working in the facility. This failure has the potential to affect all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to double lock refrigerated liquid controlled medications, failed to document and reconcile controlled medications after administration and failed to ensure shift to shift controlled medication reconciliation was completed. This failure has the potential to affect all 48 residents in the facility who receive controlled medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing Activity Program for 3 residents (R68, R74, R12), this failure has the potential to affect all 94 residents who currently reside in the facility. Findings Include: The Facility's undated Activity Policy documents It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to the Ombudsman for two (R3 and R16) of two residents reviewed for transfers in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of a bed hold for one (R3) of two residents reviewed for bed holds in a sample of 25.

Inspectors wroteBased on record review and interview the facility failed to obtain a second required screening for one resident (R58) of four reviewed for PASARR (Preadmission Screening and Resident Review) in a total sample of 25. Findings Include: R58's Interagency Certification of Screening Results dated 1/17/2017 documents Screening indicated nursing facility services are agree appropriate and NOTE: Screening is valid for 90 days from the date of the screening: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to include Post Traumatic Stress Disorder (PTSD) for two resident (R78, R88) out of 22 residents revived for care plans in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to revise the pain management care plan for one resident (R47) of 17 residents reviewed for care plans in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct ongoing scheduled pain assessments and re-evaluate one resident (R47) after increased complaints of pain of four residents reviewed for pain management in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and identify the root cause, potential triggers and implement trauma-informed care for two residents (R78, R88) with a diagnosis of Post-Traumatic Stress Disorder (PTSD) out of three residents reviewed for mood and behavior in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for one resident (R33) with a diagnosis of dementia of five residents reviewed for unnecessary medications in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to safely dispose of medications during medication pass. This failure had the potential to affect three residents (R36, R69, R95) reviewed during medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had a bedside table for one (R77) of 25 residents reviewed for resident needs in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to provide mail on Saturdays for all 94 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to post where the survey results book was located and failed to have the survey results in the binder. This has the potential to affect all 94 residents living in the facility.