Health inspection·October 23, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to answer a call light timely for one of four residents (R4) reviewed for call lights/delay in care on the sample list of six. Residents Affected - Few Findings Include: R4's MDS (Minimum Data Set) dated 8/21/23 documents R4 is alert and oriented. On 10/18/23 at 10:32 am, R4 stated it takes a long time for staff to answer R4's call light and explained that R4 had waited as long as an hour in the past for the call light to be answered. On 10/19/23 at 8:23 am, R4's call light was activated. At 8:30 am, V10 Scheduler walked by R4's room and did not answer the call light. R4 can be heard across the hall and approximately 20 feet away breathing hard and grunting. At 8:34 am, V10 then walked past R4's room again without stopping and entered the office next door to R4's room, grabbed a wheelchair and then exited the office, again walking past R4's room without answering the call light. At 8:38 am, V10 and V2 DON (Director of Nursing) both walked past R4's activated call light without answering it. At 8:39 am, V10 and V2 both walked by active R4's activated call light without answering it. At 8:40 am and 8:43 am, V17 Regional Nurse walked by R4's room with the call light activated without answering it. At 8:48 am, V11 CNA (Certified Nursing Assistant) entered R4's room to answer call light, turned it off then exited the room. At 8:50 am, R4 stated R4 was waiting for staff to take R4 to the bathroom and stated the call light had been on since 8:10 am (38 minutes). The facility Call Lights: Accessibility and Timely Response Policy dated 5/1/22 documents all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 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 3 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 10/23/2023 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)