Gallatin Manor

Based on interview and record review the facility failed to provide notification in advance of discharge for one (R1) of 4 residents reviewed for notification of discharge in a sample of 4. Findings include:R1's admission record documents an admission date of 01/13/23 with diagnoses including: disorder of urea cycle metabolism, cirrhosis of the liver, disorder of urea cycle metabolism, fatigue, dysphagia, muscle weakness, lack of coordination, history of falling, long term drug therapy, hypotension, personal history of traumatic brain injury, cognitive communication deficit, anxiety disorder, seizures, vitamin B12 deficiency, anemia, estrapyramidal and movement disorder, insomnia, schizoaffective disorder, accidental poisoning by amphetamines, vitamin D deficiency, dependence on wheelchair, abnormal posture, and muscle wasting and atrophy. R1's admission record documents V5 (Family) as R1's responsible party. R1's MDS (Minimum Data Set) dated 11/10/25 documents R1 has a brief interview of mental status (BIMS) of 01 indicating severe cognition impairment. R1's Admission/Discharge…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure dishes and utensils were properly washed/sanitized and food/drinks were covered /dated to prevent cross contamination. This failure has the potential to affect all 37 residents residing in the facility. Findings Include: On 9/16/25, during the initial walk through of the kitchen that occurred between 9:30 AM and 10:00 AM two cups of frozen ice cream were left uncovered and not labeled in the freezer. At this same time a tray full of beverages were found in the reach in refrigerator not covered nor dated/timed. During this same initial tour the dish machine was found to have no sanitizer registering on the chlorine test strip. V3 (Dietary) stated at this time that she had not been able to get any sanitizer to register on her test strip this morning either and couldn't figure out what to do. V3 went on to state that they have been having issues with the dish machine for over a week now and it has been worked on in attempt to get the sanitizer to dispense properly. V3 stated that they have been using the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure the safety of 1 (R20) of 2 residents reviewed for smoking in a sample of 25.Findings include:R20's admission Record documented an admission date of 4/12/22 with diagnoses including: cerebral infarction, expressive language disorder, dysphagia following cerebral infarction. R20's 7/10/25 Minimum Data Set (MDS) documented .Should a Brief Interview for Mental Status (BIMS) be Conducted? with the code .0. No (resident is rarely/ never understood).R20's Electronic Medical Record (EMR) documented no Smoking Evaluation Assessment since the 7/8/24 Smoking Evaluation Assessment documenting .E. Has resident had any safety issue in the past related to smoking (current of pervious setting)? b. No. G. Resident is able to safely handle lit smoking materials? . a. Yes. I. Does resident have clothing with burn holes? b. No. K. Does resident wear a smoking apron? b. No. If resident does not wear a smoking apron, is one needed? b. No. Care plan reviewed and revised for appropriate supervision and smoking directions to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to maintain records of controlled substances for accurate reconciliation and administer controlled substances as ordered for 4 (R1, R2, R3, and R5) of 5 residents reviewed for narcotic medication administration in a sample of 5. Findings include: 1. R1's admission Record documented an admission date of 1/13/23 with diagnoses including: Parkinson's disease, low back pain, Crohn's disease, dysarthria, systemic inflammatory response syndrome, and chronic pain syndrome. R1's Order Summary Report documented the following orders: 4/10/25 fentanyl patch 12 mcg (microgram)/ HR (hour) apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/16/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/21/25 fentanyl patch 12 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 4/25/25 fentanyl patch 25 mcg/hr apply 1 patch transdermally every 72 hours with an order status of discontinued, 5/1/25 fentanyl patch 50 mcg/ HR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer narcotic pain medication as ordered for 1 (R1) of 5 residents reviewed for pain control in a sample of 5. Findings include: R1's admission Record documented an admission date of 1/13/23 with diagnoses including: Parkinson's disease, low back pain, Crohn's disease, dysarthria, systemic inflammatory response syndrome, and chronic pain syndrome. R1's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section J documents under Pain Management that R1 has received a PRN (as needed) pain medication or was offered and declined in the last 5 days from the assessment date. R1's Care Plan documented a focus area initiated on 1/13/23 I currently have an alteration d/t (due to) chronic pain r/t (related to) SIRS (Systemic Inflammatory Response Syndrome). Documented interventions include Administer medication & treatments ordered by MD (Medical Doctor) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure pneumonia vaccinations were offered in accordance with Centers for Disease Control and Prevention (CDC) recommendations for five (R4, R8, R12, R25, R26) of five residents reviewed for immunizations in a sample of 24. Findings Include: 1. R25's Face Sheet documents an admission date of 3/15/2022 and documents R25 is [AGE] years old. R25's Diagnosis Information listed on the Face Sheet included type 2 diabetes mellitus and malignant neoplasm of unspecified site of unspecified female breast. R25's facility document titled Clinical-Immunizations documents PCV13 (pneumococcal 13-valent conjugate vaccine) was administered on 9/29/2014. The facility did not have documentation to show R25 was offered another pneumococcal vaccine after receiving the PCV13 on 09/29/14 nor any documentation of refusal. R25's Physician Order Sheet (POS) documents an order of: may administer immunizations per facility policy with an order date of 03/16/2022. The CDC's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide appropriate treatment and services to follow up on an abnormal urinalysis for 1 (R7) of 1 resident reviewed for urinary tract infections in a sample of 24. Findings include: R7's Face Sheet documented an admission date of 04/29/2019 and included a diagnosis of chronic kidney disease. R7's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 00 out of 15 total, which indicates a severe impairment. R7's MDS further documents in section h-bowel and bladder, that R7 is always incontinent of bladder. A Physician's Note dated 03/01/2024, found in the miscellaneous tab of R7's medical record, documents that R7 was having an increase in behaviors and insomnia. This same physician's note documents an order for a CBC (complete blood count), BMP (basic metabolic panel), and a UA (urinalysis) and C&S (culture and sensitivity). R7's Progress Notes document on 03/03/2024 Resident straight cathed (sic) via sterile…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized plan of care for the treatment of PTSD (Post traumatic Stress Disorder) for 1 of 1 (R13) residents reviewed for mental health services in a sample of 24. Findings included: On 9/9/2024 at 10:30 AM, R13 stated he was a war veteran and had PTSD (Post Traumatic Stress Disorder). R13 said that due to his PTSD, he suffers from flash backs. R13 said when he reports having issues with flash backs the staff does not really do anything to help him. R13's Face Sheet documented R13 was admitted to this facility on 10/31/2018 with diagnoses of PTSD, schizophrenia, anxiety and dementia among others. R13's Minimum Data Set (MDS) dated [DATE] documented R13's has a Brief Interview for Mental Status (BIMS) score of 10, which indicated R13 had moderate cognitive impairment. A form in R13's Electronic Health Record (EHR) titled Initial Social History and dated 11/2/2018, documents R13 was admitted to this facility with the diagnosis of PTSD…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so the facility is free of flies. This has the potential to affect all 34 residents residing in the facility. Findings include: On 8/8/23 at 9:45 AM during the lunch preparation observation flies were observed to be flying over the stove, the steam table, dish washing room and landing on the countertops. At that time, V8 (Dietary Supervisor) stated that she wishes that they could rid of the flies. On 08/08/23 at 10:00 AM, R14 was lying in bed with his eyes closed, with food that had spilled onto his sweat shirt, and four flies sitting on his sweat shirt around the food. On 8/8/23 at 10:45, V9 (Dietary Aide) stated that the flies are horrible. V9 thinks that part of the problem is that the door that leads to the outside where staff take breaks lets the flies in. They try to keep the door closed to that hallway, but the flies still make their way in. On 8/8/23 at 1:30AM, R7 who was alert to person, place and time stated that flies are bad and she needs her own fly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to allow an independent smoker the right to choose when to smoke for 1 of 3 residents (R29) reviewed for smoking in a sample of 22. Findings include: 1. R29's face sheet documented an admission date of 9/27/21 and diagnoses including: generalized arthritis, pneumonia, acute sinusitis, refractory anemia, osteomyelitis, hyperlipidemia. R29's 7/31/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R29 was cognitively intact. R29's 7/21/23 Wandering/ Elopement Risk Assessment documented R29 was a low wandering or elopement risk. R29's Smoking Evaluation assessment dated [DATE] documented a score of 7-16 requires supervision. On 8/10/23 at 11:47 AM, V4 (Social Services Director) said she completed R29's 7/14/23 Smoking Evaluation Assessment. V4 said she selected 2) Moderate problem to the questions General awareness and orientation, including ability to understand the facility safe smoking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an alleged allegation of abuse to the State Survey Agency within 24 hours for one of ome residents (R22) reviewed for abuse in a sample of 22. The Findings Include: On 8/8/23 at 9:30 AM, V11 (Ombudsman) stated that she had reported an allegation of staff to resident abuse brought to her by a resident in regards to an event that occurred on 6/9/23. V11 stated that she reported the abuse to V1 (Administrator) on 7/31/23 around 4:30 PM and that she has not heard any follow up the allegations. On 8/10/23 at 10:00 AM, V1 (Administrator) stated that he had not officially reported the incident but started his investigation. V1 stated that he would immediately report to the Illinois Department of Public Health. V1 acknowledged that this was beyond the 24 hour window of reporting the alleged incident to the state agency. V1 stated that he had contacted the staff members that were mentioned in the abuse allegation and would thoroughly investigate the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to obtain a Level II PASRR (Preadmission screening and Resident Review) screening for 1 of 10 residents (R4) reviewed for PASSR screenings in the sample of 22. The findings include: R4's face sheet document that R2's initial admission date was 11/18/2015. The same face sheet includes diagnoses as Epilepsy, unspecified, intractable, without status epilepticus, schizophrenia, unspecified, generalized anxiety disorder. R4's PAS (Preadmission Screening)/MH (Mental Health) Level 1 Determination dated 11/18/16 documents in part, Determination: Doesn't meet Severe Mental Illness Criteria Level 1 Narrative Summary Medical is primary, therefore referred to (Name of Provider) for certification.:\ The Facility's for Policy and Procedure Pre-admission Process dated 8/19/2020 notes under Procedures vii, PASRR level I for all referrals and Level II when appropriate. On 8/10/23 at 9:00am, V1 said he had called the agency that performs the screenings to request a copy of R4's Level II screening. On 8/11/23 at 10:00am, V1 said the agency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to document resident behaviors, and failed to update and implement resident centered care plans following a new diagnosis and introduction of new medication for 3 of 8 residents (R12, R14, R21) reviewed for behaviors in a sample of 22. The Findings Include: 1. R12's admitting Diagnoses Sheet dated 10/31/18 includes Schizophrenia, anxiety, bipolar, mood disorder, delusional disorder, Parkinson's, dementia, and major depressive. R12 was given a new diagnosis of other sexual dysfunction not due to a substance or known physiological condition on 05/12/23. R12's Face Sheet indicates he is his own representative. R12's August 2023 Physician's Order Sheet (POS) includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (milligram/milliliter) (Medroxyprogesterone Acetate (Contraceptive) dated 05/12/23 - Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an adequate indication for the use and sufficient monitoring of male residents prescribed an oral contraceptive (Depo Provera) for 3 of 8 residents (R12, R14, R21) reviewed for unnecessary medications in a sample of 22. The Findings Include: 1. R12's admitting Diagnoses Sheet dated 10/31/18 includes Schizophrenia, anxiety, bipolar, mood disorder, delusional disorder, Parkinson's, dementia, and major depressive. R12 was given a new diagnosis of other sexual dysfunction not due to a substance or known physiological condition on 05/12/23. R12's Face Sheet indicates he is his own representative. R12's August 2023 Physician's Order Sheet (POS) includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml (milligram/milliliter) (Medroxyprogesterone Acetate (Contraceptive) dated 05/12/23, Inject 1 milliliter intramuscularly one time a day every 90 day(s) related to other sexual dysfunction not due to a substance or known…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.