Health inspection·January 4, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few was done providing therapy to R1, V8 would not place the electric assisted standing recliner remote in eye contact of R1's vision, due to R1 liked to fidget with things, such as the television remote, call lights and anything that R1 could reach. V8 stated that therapy did not attempt to educate R1 in using the remote for the electric assisted standing recliner, due to R1 being a 2-person assist with transfers, and R1's cognitive impairment. On 1/4/25 at 12:41pm, V6 (CNA) stated that on 12/13/24, V6 was working the 2:00pm-10:30pm shift, and R1 was not in V6's group. V6 stated that at 3:30pm, V6 was told that R1 was on the floor in R1's room. V6 stated when V6 got to R1's room, R1 was laying on the floor in front of R1's electric assisted standing recliner on R1's left side, and that recliner was lifted all the way up in a standing position. On 1/4/25 at 1:13pm, V5 (Restorative Assistant) stated that V5 had conducted therapy with R1 and that R1 was a 2-person assist with a gait belt or 2 assist mechanical lift. V5 stated that on 12/13/24 at 3:30pm, V5 was walking down the hallway and heard R1 calling for help. V5 stated upon entering R1's room, V5 observed R1 laying in front of R1's electric assisted standing recliner which was in the up position. The up position would make R1 stand. V5 stated that V5 went and notified V3 (Registered Nurse/RN) that R1 had fallen. On 1/4/25 at 1:40pm, V2 (Director of Nursing) stated that V2 conducted the investigation regarding R1's fall. V2 stated that V2 attempted to interview R1 after returning from the hospital and R1 was unable to provide any details of the fall. V2 stated after interviewing staff, V2 learned that on 12/13/24 at 3:30pm, V5 heard R1 calling for assistance from R1's room. Upon V5 entering R1's room, V5 observed R1 on the floor on R1's left side, and R1's electric assisted standing recliner was in the upright standing position. V2 stated that V6 (CNA) confirmed that R1 was observed on the floor in front of R1's electric assisted standing recliner in an upright standing position. V2 stated that V3 (RN) also confirmed that upon entering R1's room, V3 observed R1 laying on R1's left side in front of R1's electric assisted standing recliner, which was in the up position, and that R1 had a hematoma to the left side of R1's forehead. V2 stated that V3 obtained orders and sent R1 to the emergency room for evaluation, and the facility was informed by the hospital that R1 had sustained a left subdural hematoma and a nondisplaced fracture of the left frontal bone. On 1/4/25 at 2:10pm, V3 (RN) stated that on 12/13/24 at 3:30pm, V5 informed V3 that R1 had fallen in R1's room. V3 stated that V3 immediately went to R1's room and upon entering observed R1 laying on the floor on R1's left side, and R1's electric standing assisted recliner was in a standing upright position. V3 stated V2 assessed R1 and noted a hematoma to the left side of R1's forehead. V3 stated that R1 was unable to provide any information on how R1 had fallen. V3 stated V3 called the facility physician and got an order to send R1 to the emergency room for evaluation. R1's Facility Census documents R1 was admitted to the facility on [DATE] and was discharged on 12/26/24 and had the following medical diagnoses; Encounter for Palliative Care, Traumatic Subarachnoid Hemorrhage, Displaced Spiral Fracture of Shaft of Left Femur, Encounter for Orthopedic Aftercare, Multiple Fractures of Ribs Right Side, Atrial Fibrillation, Atherosclerotic Heart Disease, Sjogren syndrome, Dysphagia Oropharyngeal, Cognitive Communication Deficit, Lack of Coordination, Weakness, Long Term Use of Non-Steroidal Anti-Inflammatories (NSAID), Abnormalities of Gait and Mobility, Muscle Weakness, Person Injures in Motor-Vehicle Accident, Presence of Coronary Angioplasty Implant and Graft, Hyperlipidemia, HTN, Osteitis Deformans of Multiple Sites and Peptic Ulcer. R1's Post Fall Evaluation Dated 12/13/24 at 3:30pm documents; Fall Details: Date/Time of Fall: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145347 If continuation sheet Page 2 of 3 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 01/04/2025 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 Level of Harm - Actual harm 12/13/24 at 3:25pm, Fall was not witnessed. Fall occurred in R1's room. Activity at the time of fall: R1 was using R1's remote to get up out of R1's recliner chair. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: R1 had a hematoma to the left side of R1's forehead. Did fall result in emergency room (ER) visit/hospitalization. Residents Affected - Few R1's Hospital Medical Imaging Report dated 12/13/24 documents CT scan head without contrast. Findings: The visualized base of skull structures appear intact. A scalp hematoma in the left frontal scalp is noted. This hematoma in the frontal scalp measures 8 millimeters in thickness. A subtle fracture of the left frontal bone is noted. This appears nondisplaced in the nature is appreciated best on coronal imaging. A moderately large subdural hematoma along the left parietal region is seen, measuring 10.5 millimeters in thickness. The midline of the cerebral falx is displaced towards the right by as much as 4.8 millimeters. Chronic appearing decreased attenuation in the left frontal deep white matter is seen, suggesting an area of encephalomalacia and probable prior white matter. This area of encephalomalacia was seen on 11/18/24. The left subdural hematoma represents new findings. Impression: Scalp hematoma in the left frontal area is seen. A nondisplaced fracture of the left frontal bone is suspected on this exam. Slight shift of the midline towards the right is seen, as described above. Chronic periventricular white matter small-vessel disease changes suggesting microvascular angiopathy changes and an area of encephalomalacia in the left frontal area is seen but appears unchanged since 11/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145347 If continuation sheet Page 3 of 3