Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
Based on interview and record review, the facility failed to prevent two episodes of physical abuse between
residents for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10.
This resulted in R1 hitting R2 on top of the head with a metal cane then R1 throwing a cup and eating
utensils at R2, hitting R2 in the arm, causing psychosocial harm for R2 and R9, along with a hematoma to
the top of R2's head.
Findings Include:
The facility's Abuse, Neglect and Exploitation Policy dated 2/28/23 documents, abuse is 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.
Willful means the individual must have acted deliberately, not that the individual must have intended to
inflict injury or harm. Physical Abuse include, but is not limited to hitting, slapping, punching, biting and
kicking.
The facility's Final Incident Report dated 9/22/23 documents on 9/17/23, it was reported that R1 and R2
were sitting in the dining room when R1 went over to R2 and struck R2 on the head with R1's cane. An
investigation has been completed and staff interviews confirm that R1 struck R2 with R1's cane. R1 was not
exhibiting any threatening behavior prior to R1's action and did not appear to even know why R1 had done
so. R2 stated R1 hit R2 in the head with R1's cane. R2 does not know why R1 did this and reported that
there was no altercation between them prior to this. R1 stated R1 doesn't know why R1 hit R1's peer (R2)
and had no intention of hurting R2. Other residents present during this incident confirmed this incident, but
none had any idea why R1 took this action.
On 10/12/23 at 9:05 am, R2 stated R2 was sitting in the dining room at dinner time when R1, who was at a
different table but near R2, stood up and hit R2 on top of the head with R1's cane. R2 stated R2 had a large
lump on R2's head and a headache after it happened. R2 explained the nurse put ice on it and sent R2 to
the hospital for evaluation. R2 stated the lump went down with ice but that R2 had a headache for a couple
of days. R2 also stated that after that happened, a couple weeks later, R1 threw R1's cup at R2 hitting R2 in
the arm. R2 explained the facility then moved R1 to a different table, away from R2, but it was too late, (R1)
already had hit me (R2) a second time. R2 stated R2 was afraid of R1 explaining, I (R2) don't want (R1)
around me, I (R2) don't know what (R1) will do.
On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was not present when R1 hit R2
with R1's cane however R1 told V12 about it saying R1 did it because R2 wouldn't talk to R1. V12 stated
V12 explained that R2 was hard of hearing and that is probably why R2 didn't respond to R1. V12 then
stated that after the first incident, V12 was told by V8 Activity Aide/CNA (Certified
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
145347
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0600
Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm. V12 stated R2 is now afraid of R1.
Level of Harm - Actual harm
On 10/12/23 at 12:39 pm, V8 stated V8 was in the dining room and when V8 walked by R2, who was sitting
at the table along with R8, R9 and R10, R2 reported that R1 just threw a glass and silverware at (R2) that
hit R2 in the arm. V8 explained R8, R9 and R10 all seen R1 throw items at R2, and thought it was wrong of
R2 to throw the items. V8 stated V8 considers R1's actions to be abusive toward R2.
Residents Affected - Few
R9's MDS (Minimum Data Set) dated 9/20/23 documents R9 is alert and oriented.
On 10/12/23 at 1:47 pm, R9 stated R9, R2, R8 and R10 were all eating lunch when R1 threw a pop can at
R2, hitting R2 in the upper arm, then a cup, that was not full was thrown and hit R2, then a knife that didn't
hit R2 but instead landed on the floor, sliding under the table and then the rest of R2's utensils, which also
hit the floor. R9 explained, this isn't the first incident with (R1) either. A couple of weeks prior, (R1) was
walking past (R2) and hit (R2) on top of (R2's) head with (R1's) metal cane. R2 ended up getting a big knot
on the top of R2's head and instantly complained of a headache. R9 stated R2 is scared of R1 now and
every time R1 walks past R2 at the table, R1 taunts R2 by telling R2 to look at something that isn't there. V9
explained V9 thinks R1 is trying to be funny but that isn't funny after hitting (R2). (R1) could easily walk a
different way but (R1) always walks right by (R2) and it's intimidating to (R2). R9 stated we {R8, R9 and
R10} all sit there and wonder if it's going to be our turn next and that scares me (R9) because I'm in this
wheelchair due to a broken ankle, I (R9) just can't get up and walk away from (R1).
On 10/16/23 at 9:00 am, R1 confirmed R1 hit R2 over the head with R1's cane while in the dining room and
stated R1 was upset, not necessarily at R2 but in general, and that is why R1 did it. R1 also confirmed R1
hit R2 with a cup in the dining room explaining that R1 did not throw the cup at R2 but instead swiped the
table with his hand, pushing a cup and utensils off the table in R2's direction and was trying to hit R2 with
them.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to operationalize their Abuse, Neglect and
Exploitation Policy for reporting and investigating abuse allegations for five of five residents (R1, R2, R8, R9
and R10) reviewed for abuse on the sample list of 10.
Residents Affected - Some
Findings Include:
The facility Abuse, Neglect and Exploitation Policy dated 2/28/23 documents it is the policy of this facility to
provide protection 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. An immediate investigation is warranted when suspicion of abuse, neglect or
exploitation, or reports of abuse, neglect or exploitation occur. Identify and interview all involved persons,
including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the
allegations. Focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has
occurred, the extent and cause. The facility will have written procedures that include reporting of all alleged
violations to the Administrator, state agency, adult protective services and to all other required agencies.
On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was told by V8 Activity Aide/CNA
(Certified Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm. V12 stated R2 is now
afraid of R1.
On 10/12/23 at 12:39 pm, V8 stated last week when V8 was in the dining room, V8 walked by the table that
R2, R8, R9 and R10 were sitting at and R2 reported that R1 had just thrown a glass and silverware at R2,
hitting R2 in the arm. V8 stated V8 considered R1's actions to be abusive towards R2, so V8 reported the
situation to administration and wrote up a witness statement.
V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and
silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was
not hurt and apparently no one else was hurt at the table as a result of R1's action.
On 10/12/23 at 1:47 pm, R9 confirmed that last week, R1 threw items including a soda can, cup and
utensils at R2, hitting R2 in the arm, while sitting in the dining room.
On 10/12/23 at 2:15 pm, V1 Administrator stated V1 was not aware of R1 throwing items toward R2 and
hitting R2 with said items on 10/5/23 until approximately 10 minutes ago, due to being out of the facility. At
this time, V2 DON (Director of Nursing) stated after V2 was told about the situation, V2 watched the video
surveillance but did not do any other type of investigation. V2 explained in the video, R1 could be seen
swiping R1's arm across the table, knocking items onto the floor but that V2 did not actually see R1 throw
anything at R2. V2 also stated that V2 did not interview R1, R2, R8, R9 and R10 or any other resident
and/or staff in the dining room. V2 also stated that V2 did not report the second abuse incident to IDPH
(Illinois Department of Public Health). V1 then stated, V2 who was working as the Abuse Coordinator in
V1's absence and should have done more than just watch the video because it isn't really clear. You can tell
(R1) swiped the table but can't see if (R1) hit (R2) with items or not. V1 explained V2 should have talked
with residents and staff and also reported it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0609
Level of Harm - Minimal harm
or potential for actual harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review, the facility failed to report an allegation of physical abuse between
two residents (R1, R2) reviewed for abuse on the sample list of 10.
Residents Affected - Few
Findings Include:
On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was told by V8 Activity Aide/CNA
(Certified Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm.
On 10/12/23 at 12:39 pm, V8 stated last week when V8 was in the dining room, V8 walked by R2's table
and R2 reported that R1 had just thrown a glass and silverware at R2, hitting R2 in the arm. V8 stated V8
considered R1's actions to be abusive towards R2, so V8 reported the situation to administration and wrote
up a witness statement.
V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and
silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was
not hurt and apparently no one else was hurt at the table as a result of R1's action.
On 10/12/23 at 2:15 pm, V1 Administrator stated V1 was not aware of R1 throwing items toward R2 and
hitting R2 with said items on 10/5/23 until approximately 10 minutes ago, due to being out of the facility. At
this time, V2 DON (Director of Nursing) stated V2 was made aware of the alleged abuse by V8 but that V2
did not report the abuse allegation to IDPH (Illinois Department of Public Health).
V1 stated V2 should have reported the alleged abuse to IDPH.
The facility Abuse, Neglect and Exploitation Policy dated 2/28/23 documents the facility will have written
procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective
services and to all other required agencies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to investigate an allegation of physical abuse
between two residents (R1, R2) reviewed for abuse on the sample list of 10.
Residents Affected - Few
Findings Include:
On 10/12/23 at 12:39 pm, V8 stated last week while in the dining room, R2 reported to V8 that R1 threw a
glass and silverware at R2, hitting R2 in the arm. V8 stated V8 reported the situation to administration and
wrote a witness statement due to V8 considering R1's actions to be abusive in nature toward R2.
V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and
silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was
not hurt and apparently no one else was hurt at the table as a result of R1's action.
On 10/12/23 at 2:15 pm, V1 Administrator stated V1 was not aware of R1 throwing items toward R2 and
hitting R2 with said items on 10/5/23 until approximately 10 minutes ago, due to being out of the facility. At
this time, V2 DON (Director of Nursing) stated after V2 was told about the situation, V2 watched the video
surveillance but did not do any other type of investigation. V2 explained in the video, R1 could be seen
swiping R1's arm across the table, knocking items onto the floor but that V2 did not actually see R1 throw
anything at R2. V2 also stated that V2 did not interview R1, R2, any other resident and/or staff in the dining
room.
The facility Abuse, Neglect and Exploitation Policy dated 2/28/23 documents an immediate investigation is
warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation
occur. Identify and interview all involved persons, including the alleged victim, alleged perpetrator,
witnesses, and others who might have knowledge of the allegations. Focus the investigation on determining
if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop care plans and implement fall
prevention interventions for residents at risk for falls and failed to thoroughly investigate a fall and
implement appropriate post fall interventions for three of three residents (R5, R6 and R7) reviewed for falls
on the sample list of 10. These failures resulted in R5 having multiple falls resulting in a compression
fracture of L5.
Findings Include:
The facility Fall Prevention Program dated June 2023 documents the fall prevention program will be
implemented to ensure all resident's safety in the facility whenever possible. This program should include a
measure that determines each resident's needs by assessing the risks for falls and implementing
appropriate interventions to provide the necessary supervision, and assistive devices are utilized as
necessary. As part of the initial assessment, identify with a history of falls and risk factors for subsequent
falling. Risk factors causing the fall should be identified. Identify the root causes of the fall incident, which
could be related to the resident's current or declining medical condition or worsening behavior. For an
individual who has fallen, staff will attempt to define possible root cause(s) of the fall. Contributing fractures
can include but not limited to resident's gait, balance, and current medications that may be associated with
dizziness or falling. Collect and evaluate any information until either the cause of the falling is identified or
can be speculated as to what was the resident trying to do causing the fall, or it is determined that the
cause cannot be found or that finding a cause would not change the outcome or the management of falling
and fall risk. Based on the preceding assessment, the staff and or physician will identify pertinent
interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If
the underlying causes cannot be readily identified or corrected, staff will try various relevant interventions,
based on assessment until falling reduces or stops or until a reason is identified for its continuation. If the
resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible
reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the
continued relevance of current interventions.
1) R5's ongoing Census documents R5 was admitted to the facility on [DATE].
R5's undated Profile Sheet document the following diagnoses: Orthostatic Hypotension, Abnormalities of
Gait and Mobility, Osteoarthritis, and Mild Cognitive Impairment.
R5's MDS (Minimum Data Set) dated 9/28/23 documents R5 has Moderately Impaired Cognition, is
non-ambulatory and requires extensive assistance of one staff for bed mobility, transfers and locomotion.
R5's Fall Risk Assessments dated 9/22/23, 9/23/23, 9/26/23 and 9/27/23 all document R5 is at risk for falls.
R5's Care Plan dated 9/22/23 documents R5 is at risk for falls with interventions including: evaluate fall risk,
determine ability to transfer, assist resident with transfers and ambulation.
R5's updated Care Plan dated 9/26/23 documents R5 has had an actual fall with minor injury due to Poor
Balance, Unsteady gait, and confusion with interventions to continue interventions on the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0689
at-risk plan, dump wheelchair, encourage to sit in more visual area, remove foot pedals, and send to ER
(Emergency Room) for further evaluation.
Level of Harm - Actual harm
Residents Affected - Few
On 10/11/23 at 11:32 am, hanging on the wall in R5's room, at the head of the bed were two signs. One
documents Call don't fall. The second sign, which was hanging upside down in the same location
documents If you need help, please push the red button on your call light and wait for help.
R5's Progress Notes document the following:
9/23/23 - Housekeeping staff alerted RN (Registered Nurse) that R5 was on the floor. Upon getting to R5,
R5 was noted lying on the floor. R5 stated that R5 was attempting to get up to go look for her husband. R5
is weak and ended up sliding out of the wheelchair.
9/26/23 - noted to be on floor by DON (Director of Nursing) and CNA (Certified Nursing Assistant). R5 was
did not have footwear on, call light was within reach.
9/27/23 two entries, both by V6 RN - 1) notified by another resident that R5 was on the floor. When leaving
dining room and looking down hall, noticed R5 sitting on the floor, against the wheelchair with R5's right leg
bent up on leg rest and 2) was notified by another resident that R5 fell out of the wheelchair in the dining
room. Upon entering, R5 was noted to be on the floor, leaning up against the wheelchair with R5's head
resting on the seat. R5 did not have shoes on. Other staff members assisted R5 back into the wheelchair
and R5 was placed near nurses station. R5 denies pain and hitting R5's head. Given order to send to the
hospital.
On 10/12/23 at 11:30 am, V2 DON stated R5 was originally admitted to the facility due to falling at home
and R5's husband not being able to take care of her. V2 explained R5 is very impulsive and thinks R5 can
do things for herself because R5 is wanting to go back home to her husband. V2 provided more details
related to the above falls. V2 explained on 9/23/23, R5 was on the floor near the hallway bathroom, after
sliding out of R5's wheelchair while looking for her husband. V2 stated a new intervention was implemented
to sit in a more visual area. V2 confirmed the intervention was not appropriate as sitting in a more
visualized area would not prevent R5 from sliding out of the chair. V2 explained on 9/26/23, R5 was
attempting to get out of bed by R5's self and was found on the floor. V2 stated V2 is unsure why R5 was
trying to get up out of bed because V2 didn't investigate the fall or talk to the resident about the fall but
instead just went off of the witness statement which documented that she was wanting to get dressed. V2
stated a new intervention of visual cues were posted in R5's room to call for assistance. V2 confirmed that
the visual cues should be some place that R5 can see them, other than being behind R5's head, and
positioned so R5 can read them. V2 stated V2 is only aware of one fall on 9/27/23 and that is the one where
(R5) sustained the fracture and it was reported to IDPH (Illinois Department of Public Health. V2 stated V2
only has one incident report from that day, and it was for the fall that occurred at 7:15 pm, in the hallway,
when R5 slipped out of the wheelchair. V2 believes R5 was trying to get the foot pedals off of the
wheelchair so the new intervention was to remove the foot pedals and dump the seat of the wheelchair. V2
stated no interventions were implemented for the other fall that day, as V2 was not aware of a second fall.
R5's Emergency Department Adult Provider Note dated 9/28/23 by V9 Hospital Physician documents R5
was brought to the emergency room on 9/27/23 after trying to lift R5's self up from a wheelchair, slipped
and fell to the floor from the wheelchair. R5 is complaining of pain to the lower back. This note documents
R5 has an acute L5 compression fracture.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
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
145347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gilman Healthcare Center
1390 South Crescent Street, Box 307
Gilman, IL 60938
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 0689
R5's Radiology Results dated 9/27/23 documents there is minimal height loss and a faintly visible fracture
line through the superior endplate of L5 consistent with an acute compression fracture.
Level of Harm - Actual harm
Residents Affected - Few
2) On 10/11/23 at 1:30 pm, R6 was lying in bed with a seated walker next to the bed. R6 stated the last
time R6 fell, R6 had bent down to pick something up off the floor and R6's knee gave out, explaining R6
has two bad knees that give out at times.
R6's October 2023 Physician Orders document an order on 10/2/23 to wear a soft knee brace for pain.
R6's MDS (Minimum Data Set) dated 9/12/23 documents R6 has moderately impaired cognition and
requires supervision with transfers and ambulation.
R6's Progress Notes dated 10/6/23 documents R6 sitting on buttocks on the floor in the dining room. R6
stated R6's right knee gave out. Fall was witnessed by other residents in the dining room.
On 10/12/23 at 10:52 am, V2 DON (Director of Nursing) stated R6's fall was not investigated, and no new
post fall interventions were implemented.
3) R7's ongoing Census documents R7 was admitted to the facility on [DATE].
R7's Fall Risk Assessments dated 9/18/23 documents R7 is at risk for falls.
R7's Care Plan dated 10/2/23 does not contain an at risk for falls care plan or any fall prevention
interventions.
On 10/12/23 at 11:12 am, V2 DON (Director of Nursing) confirmed R7 does not have an at risk care plan
for falls and did not have any fall prevention interventions put into place at the time of admission, even
though R7 was at risk for falls at the time of admission to the facility. V2 stated R7 should have had one in
place with standard fall prevention interventions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145347
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the October 16, 2023 survey of GILMAN HEALTHCARE CENTER?
This was a inspection survey of GILMAN HEALTHCARE CENTER on October 16, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GILMAN HEALTHCARE CENTER on October 16, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.