Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**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 policy and Ability to follow smoking
policy because R29 would ask to go out to smoke at times that were not designated smoking times. V4 said
if R29 was to sleep through a designated smoking time R29 would come to the nurse's station and ask
several times to go out to smoke and would have to be reeducated on the facility smoking policy and told
R29 would have to wait until the next designated smoking time. V4 said all residents had to be supervised
during smoking per the facility policy.
On 8/9/23 at 1:07 PM, R29 was observed independently ambulating herself in her wheelchair out to the
designated smoking area. R29 was observed to safely smoke a cigarette and extinguish it. R29 said she
was able to independently wheel herself outside, light her cigarette, smoke her cigarette, and extinguish it.
R29 said the facility would not let any residents go outside to smoke if it was not during the designated
smoking times. R29 said if she wakes up in the middle of the night and wants go smoke facility staff will tell
her no.
On 8/9/23 at 1:00 PM residents were lined up in the 100-hallway leading to the door of the designated
smoking area. V6 (Activities Assistant) was handing residents cigarettes out of a box containing all the
resident's cigarettes. V5 (Activities Director) was lighting resident's cigarettes for them on the designated
smoking area patio. V5 said she was lighting all the resident's cigarettes because the facility smoking policy
documented no residents were allowed to handle lighters. V5 said no residents were allowed to smoke
without staff supervision. When V5 was asked why a resident had to be supervised while smoking if they
were alert and oriented, able to independently smoke, and was not an
(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 13
Event ID:
146054
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
elopement risk V5 said that was the facility policy. V6 said residents are given one cigarette at six of the
designated smoking times and two cigarettes at the 1:00 PM - 1:15 PM and 8:30 PM - 8:45 PM designated
smoking times. V5 said residents were given two cigarettes at the 8:30 PM - 8:45 PM designated smoking
time because no residents would be allowed to smoke again until the 6:30 AM - 6:45 AM designated smoke
time. V5 said if a resident requested to go outside to smoke at a time other than the designated smoking
times they would be told no they had to wait until the next designated smoking time. V5 said in the past
independent smokers were allow to go outside to smoke whenever they wanted to and that started to cause
problems with the unsafe smokers getting upset they could not go outside to smoke whenever they wanted
to so the facility changed the policy to all residents could only go outside at designated smoking times.
The facility's 10/7/21 Smoking, Tobacco, & Nicotine Products Safety- Resident policy documented in part .
5. All residents, visitors and staff shall smoke in designated area and at designated times only . 6. The
facility shall establish reasonable designated times to provide smoking opportunities to residents requiring
assistance and/ or supervision. These times are subject to change according to staffing and census . 7 A
facility staff member must be available to assist and ensure the safety of all residents during the smoking
activities per plan of care, unless an approved guest/ volunteer is present while the resident is smoking .
12. Supervised smoking will be 15 minutes for each smoking session .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 2 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
**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 allegation.
V1 provided the long term care facility report of serious injury incident report. This document contains the
information provided from V11 regarding the alleged abuse that was reported to her from another resident.
This had a report date listed as 8/10/23 and the incident date listed as 6/9/23. V1 confirmed that he was
first notified of the allegation on 7/31/23 from V11. In the incident report it states that V11 (Certified Nurse
Assistant)(CNA) and V12 (CNA) were verbally abusive to R22 when transporting her to her room and in the
dining room.
R22's admission record documents an admission date of 1/13/23. Diagnosis information on this same
document include the following: toxic effect of other organic solvents, anxiety disorder, cognitive
communication deficit, personal history of traumatic brain injury, and schizoaffective disorder.
R22's Quarterly Minimum Data Set (MDS) dated [DATE] Section G documents that R22 has a Brief
Interview of Mental Status score of 3, indicating a severe cognitive impairment.
The facilities Resident Right To Freedom From Abuse, Neglect, and Exploitation Policy and Procedure
dated 2022 documents in part IV When the facility has identified abuse, the facility will take all appropriate
steps to remediate the noncompliance and protect residents from additional abuse immediately. the facility
will increase enforcement action, including, but not limited to B. Reporting the alleged violation and
investigation within required timeframes pursuant to the Federal and State statues and regulations .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 3 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
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 could not find where a Level II
screening was done for R4. V1 said that he requested that a Level II screening be performed.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 4 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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 physiological condition.
R12s May 2023 Medication Administration Record (MAR) documents he received an injection of
Depo-Provera on 05/15/23.
R12's Care Plan includes a focus area: (R12) demonstrates behaviors that include story fabrication,
argumentative with staff, soliciting staff for money and gifts, and inappropriate interactions and comments to
staff. Goal: (R12) episodes of inappropriate behavior will decrease through review date. Interventions: Make
(R12) aware when behaviors are inappropriate. Monitor and report behaviors to nurse. Report abusive or
aggressive behaviors to the appropriate supervisor. Date Initiated: 02/22/2019. Revision on: 04/25/2022.
There is no documentation on R12's care plan indicating sexually inappropriate behavior towards other
residents in the facility or the introduction of Depo-Provera for this behavior.
R12's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicates he is moderately cognitively
impaired with a brief interview for mental status (BIMS) score of 9. R12 requires extensive one person
assistance for bed mobility and transfers, requiring supervision and set up only for locomotion in his room
or corridor. R12 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking,
pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at
others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts,
disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or
disruptive sounds.
R12's behavior tracking from July 2022 to present was reviewed. Problem: Inappropriate Sexual Behavior.
Interventions: 1. Remove R12 from the situation to protect R12's safety and the rights of others. 2. Make
R12 aware of behavior by educating him on appropriate behavior. 3. Distract and redirect R12 from
inappropriate behavior. 4. Report behavior to Administrator, immediately. R12 is documented to have 15
documented episodes of inappropriate sexual behavior with no follow-up documentation describing the
incident or who else was involved. R12's behavior notes are not specific to the behavior manifested or
against whom.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 5 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 08/10/23 at 2:49 PM, R12 was sitting in the dining room at a table by himself drinking juice. R12 was
asked if he had given consent to receive an injection of Depo-Provera and had no response. When asked if
he had been getting a new shot, he stated, Yes, and he wasn't going to talk about that. R12 then stated, I
love you and I would marry you if you weren't married. R12 did not possess the mental capacity to
comprehend what was being asked of him. R12 was observed daily from 08/08/23 to 08/11/23
self-propelling in his wheelchair or walking with his walker about the facility.
2. R14 admitted to this facility on 05/25/23 with diagnoses to include Alzheimer's disease, dementia, diffuse
large b-cell lymphoma, extra [NAME] and solid organ sites, and an additional diagnosis dated 05/30/23 of
unspecified sexual dysfunction not due to a substance or known physiological condition.
R14's August 2023 POS includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml
(Medroxyprogesterone Acetate (Contraceptive) dated 05/30/23 - Inject 1 milliliter intramuscularly one time a
day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological
condition.
R14's May 2023 MAR documents he received an injection of Depo-Provera on 05/31/23.
R14's care plan included a focus: I currently have an alteration in my behavior status at times sexually
inappropriate with staff. Date initiated 6/8/23. Goal: I will be compliant with labs and diagnostics if ordered
by my doctor through the review date. This medication has a Black Box Warning resident will have no
complications through review date. I will have fewer episodes of being sexually inappropriate to less than
daily by review date. Intervention: 2 staff with care PRN (as needed). My behaviors will be monitored every
shift and documented. I will be monitored for a change in condition and the MD (Medical Doctor) will be
notified. Administer medication and treatments ordered by MD and monitor for side effects to current
medication regimens. Explain all procedures to the (SPECIFY) before starting and allow the resident (X
minutes) to adjust to changes. Monitor behavior episodes and attempt to determine underlying cause.
Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
All interventions included an initiated date of 6/8/23.
R14's most recent quarterly MDS dated [DATE] indicates he is severely cognitively impaired with a BIMS
score of 6. R14 requires extensive two-person assistance for bed mobility and transfers, and extensive one
person assist for ambulating in his room or corridor. R14 is assessed to exhibit no physical, verbal, or
behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually,
threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching
self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, or disruptive sounds.
The facility was only able to provide R14's behavior tracking sheet dated 07/11/23 through 07/25/23 which
indicated R14 displayed one sexually inappropriate physical behavior on 07/23/23 at 4:26 PM. R14's record
did not document what this behavior was or with whom.
On 08/11/23 at 11:00 AM, R14 stated he has not received any type of shot or injection related to
inappropriate sexual behavior, and stated he was doing just fine.
3. R21's face sheet notes R11 was admitted to the facility on [DATE]. The same face sheet lists some of
R21's diagnoses as: unspecified dementia, unspecified severity, without behavioral
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 6 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0744
Level of Harm - Minimal harm
or potential for actual harm
disturbances, psychotic disturbance, mood disturbance and anxiety, other sexual dysfunction not due to a
substance or known physiological condition, schizophrenia, unspecified.
R21's MDS dated [DATE] notes that R21 has a BIMS of 02 which indicates that R21 has severe cognitive
impairment. R21 is unable to be interviewed.
Residents Affected - Few
R21's Physician orders dated 8/1/23 - 8/31/23 note an order for Depo-Provera Suspension 150mg/ml Inject
1 ml intramuscularly one time a day every 90 days, with a start date of 10/13/19 according to the consent
signed by V20 (Guardian).
R21's MAR documents the following dates he received a Depo-Provera infection - 09/29/22, 12/28/22,
03/28/23, and 06/26/23.
R21's care plan notes R21 has behavior symptoms associated with sexually inappropriate behavior with
staff, resident, visitors. On 4/30/21 R21 grabbed a staff members breast. Some interventions listed are R21
will be redirected by staff when inappropriate touching is initiated, Redirect R21 away from risky situations,
speak with R21 to see what he is needing/wanting, redirect R21 to room or quiet area to calm. There is no
documentation of R21's care plan including a focus area for the injection of Depo-Provera.
Facility Document labeled Behavior Summary Report for the week ending through 8/13/22 through the
week ending 8/12/23 indicate R21 had 8 documents occurrences of sexually inappropriate behavior with
distraction and redirection provided.
On 08/10/23 at 12:34 PM, when asked if V1 (Administrator) had any documentation regarding R12, R14, or
R21's sexually inappropriate behavior for each date marked on the tracking sheets, he stated there was
nothing really documented to describe what happened, just the code that it happened and the code for the
intervention used. V1 stated he did recall the incident on 07/23/23 stating R14 asked the nurse to get in bed
with him when she was passing his medication on that day. V1 stated that nurse no longer works here, but
did report this to him so that he could be aware of the comment made. When asked if he had any
documentation of that interaction, V1 stated he did not. V1 stated there had been no reporting of
inappropriate sexual behavior towards residents that he recalled, just mainly with staff.
On 08/10/23 at 1:00 PM, V15 (Certified Nursing Assistant/CNA) stated R12, R14, or R21 have never had
sexual inappropriate behavior towards her or any residents that she is aware of.
On 08/11/23 at 8:10 AM, CNAs V17, V18, and V19 stated they had not witnessed any inappropriate sexual
behavior from R12, R14, or R21 towards other residents lately.
On 08/10/23 at 3:19 PM, V4 (Social Services) stated that the CNAs document resident behaviors on their
tracking sheet, report to the nurse, and the nurse lets her know and she makes a note in the record. When
asked if there were any notes that would explain what the behavior of R12, R14, or R21 was besides
sexually inappropriate behavior and who it involved other than staff, V4 stated they did not document
specifics, but would definitely make that addition of some type of incident write up in the future. V4 stated
their behaviors were towards staff. There was no other documentation provided to explain what these three
residents' behaviors were specifically, or to whom they were against.
On 08/11/23 at 2:42 PM, V23 (Licensed Practical Nurse) states she is aware of incidents when R12,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 7 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0744
Level of Harm - Minimal harm
or potential for actual harm
R14, R21 have inappropriately touched staff while CNAs are providing care. She stated what normally
happens is the CNAs chart, tell the nurse, and the nurse reports this to social services so they can address
the situation.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 8 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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 physiological condition.
R12s May 2023 Medication Administration Record (MAR) documents he received an injection of
Depo-Provera on 05/15/23.
R12's Care Plan includes a focus area: (R12) demonstrates behaviors that include story fabrication,
argumentative with staff, soliciting staff for money and gifts, and inappropriate interactions and comments to
staff. Goal: (R12) episodes of inappropriate behavior will decrease through review date. Interventions: Make
(R12) aware when behaviors are inappropriate. Monitor and report behaviors to nurse. Report abusive or
aggressive behaviors to the appropriate supervisor. Date Initiated: 2/22/2019. Revision on: 04/25/2022.
There is no documentation on R12's care plan indicating sexually inappropriate behavior towards other
residents in the facility.
R12's most recent quarterly minimum data set (MDS) dated [DATE] indicates he is moderately cognitively
impaired with a brief interview for mental status (BIMS) score of 9. R12 requires extensive one person
assistance for bed mobility and transfers, requiring supervision and set up only for locomotion in his room
or corridor. R12 is assessed to exhibit no physical, verbal, or behavioral manifestations of hitting, kicking,
pushing, scratching, grabbing, abusing others sexually, threatening others, screaming at others, cursing at
others, physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts,
disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, or
disruptive sounds.
R12's behavior tracking from July 2022 to present was reviewed - Problem: Inappropriate Sexual Behavior.
Interventions: 1. Remove R12 from the situation to protect R12's safety and the rights of others. 2. Make
R12 aware of behavior by educating him on appropriate behavior. 3. Distract and redirect R12 from
inappropriate behavior. 4. Report behavior to Administrator, immediately. R12 is documented to have 15
documented episodes of inappropriate sexual behavior with no follow-up documentation describing the
incident or who else was involved.
On 08/10/23 at 2:49 PM, R12 was sitting in the dining room at a table by himself drinking juice. R12 was
asked if he had given consent to receive an injection of Depo-Provera and had no response. When asked if
he had been getting a new shot, he stated, Yes, and he wasn't going to talk about that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 9 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R12 then stated, I love you and I would marry you if you weren't married. R12 did not possess the mental
capacity to comprehend what was being asked of him. R12 has been observed daily during this survey
from 08/08/23 to 08/11/23 self-propelling in his wheelchair or walking with his walker about the facility.
There were no observations of inappropriate behavior between R12 and other residents.
2. R14 admitted to this facility on 05/25/23 with diagnoses to include Alzheimer's disease, dementia, diffuse
large b-cell lymphoma, extra [NAME] and solid organ sites, and an additional diagnosis dated 05/30/23 of
unspecified sexual dysfunction not due to a substance or known physiological condition.
R14's August 2023 POS includes a prescription for Depo-Provera Intramuscular Suspension 150 mg/ml
(Medroxyprogesterone Acetate (Contraceptive) dated 05/30/23, Inject 1 milliliter intramuscularly one time a
day every 90 day(s) related to other sexual dysfunction not due to a substance or known physiological
condition.
R14's May 2023 MAR documents he received an injection of Depo-Provera on 05/31/23.
R14's care plan included a focus: I currently have an alteration in my behavior status at times sexually
inappropriate with staff. Goal: I will be compliant with labs and diagnostics if ordered by my doctor through
the review date. This medication has a Black Box Warning resident will have no complications through
review date. I will have fewer episodes of being sexually inappropriate to less than daily by review date.
Intervention: 2 staff with care PRN (as needed). My behaviors will be monitored every shift and
documented. I will be monitored for a change in condition and the MD (Medical Doctor) will be notified.
Administer medication and treatments ordered by MD and monitor for side effects to current medication
regimens. Explain all procedures to the (SPECIFY) before starting and allow the resident (X minutes) to
adjust to changes. Monitor behavior episodes and attempt to determine underlying cause. Consider
location, time of day, persons involved, and situations. Document behavior and potential causes. Date
Initiated: 06/08/23.
R14's most recent quarterly MDS dated [DATE] indicates he is severely cognitively impaired with a BIMS
score of 6. R14 requires extensive two person assistance for bed mobility and transfers, and extensive one
person assist for ambulating in his room or corridor. R14 is assessed to exhibit no physical, verbal, or
behavioral manifestations of hitting, kicking, pushing, scratching, grabbing, abusing others sexually,
threatening others, screaming at others, cursing at others, physical symptoms such as hitting or scratching
self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, or disruptive sounds.
The facility was only able to provide R14's behavior tracking sheet dated 07/11/23 through 07/25/23 which
indicated R14 displayed one sexually inappropriate physical behavior on 07/23/23 at 4:26 PM. R14's record
did not document what this behavior was or with whom.
On 08/11/23 at 11:00 AM, R14 stated he was not receiving any type of shot or injection related to
inappropriate sexual behavior, and stated he was doing just fine.
3. R21's face sheet notes R11 was admitted to the facility on [DATE]. The same face sheet lists some of
R21's diagnoses as: unspecified dementia, unspecified severity, without behavioral disturbances, psychotic
disturbance, mood disturbance and anxiety, other sexual dysfunction not due to a substance or known
physiological condition, schizophrenia, unspecified.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 10 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R21's MDS dated [DATE] notes that R21 has a BIMS of 02 which indicates that R21 has severe cognitive
impairment.
R21's Physician orders dated 8/1/23 - 8/31/23 note an order for Depo-Provera Suspension 150mg/ml Inject
1 ml intramuscularly one time a day every 90 days, with a start date of 10/13/19 according to the consent
signed by V20 (Guardian).
R21's MAR documents the following dates he received a Depo-Provera injection - 09/29/22, 12/28/22,
03/28/23, and 06/26/23.
R21's care plan notes R21 has behavior symptoms associated with sexually inappropriate behavior with
staff, resident, visitors. On 4/30/21 R21 grabbed a staff members breast. Some interventions listed are R21
will be redirected by staff when inappropriate touching is initiated, redirect R21 away from risky situations,
speak with R21 to see what he is needing/wanting, redirect R21 to room or quiet area to calm. There is no
documentation of R21's care plan including a focus area for the injection of Depo-Provera.
On 08/10/23 at 12:34 PM, when asked if V1 (Administrator) had any documentation regarding R12, R14, or
R21's sexually inappropriate behavior for each date marked on the tracking sheets, he stated there was
nothing really documented to describe what happened, just the code that it happened and the code for the
intervention used. V1 stated he did recall the incident on 07/23/23 stating R14 asked the nurse to get in bed
with him when she was passing his medication on that day. V1 stated that nurse no longer works here, but
did report this to him so that he could be aware of the comment made. When asked if he had any
documentation of that interaction, V1 stated he did not. V1 stated there had been no reporting of
inappropriate sexual behavior towards residents that he recalled, just mainly with staff.
On 08/10/23 at 1:00 PM, V15 (Certified Nursing Assistant/CNA) stated R12, R14, or R21 have never had
sexual inappropriate behavior towards her or any residents that she is aware of.
On 08/11/23 at 8:10 AM, CNA's V17, V18, and V19 stated they had not witnessed any inappropriate sexual
behavior from R12, R14, or R21 towards other residents lately.
On 08/10/23 at 2:12 PM, V20 (Guardian) was asked if she had given consent for R21 to receive injections
of Depo-Provera. V20 stated she vaguely remembered the facility calling in 2019 explaining it was the
physician's recommendation R21 be placed on this drug. V20 stated if her memory served her correctly,
R21 was reported to have gone into a female resident's room but does not remember exact details. She
stated she did give verbal approval for this drug to be started due to being the physician's recommendation
and was not going to question that recommendation.
On 08/10/23 at 1:34 PM, an attempt to contact V21 (Family Member/POA of R14 - Power of Attorney) was
made with no success.
On 08/10/23 01:41 PM, V2 (Director of Nursing - DON) stated the physician had not ordered testosterone
levels to be drawn on R12, R14, or R21. When asked about consents for the Depo-Provera injections V2
stated R12 was his own person, R14's admission packet and any consents sent to his POA (Power of
Attorney) for signature had not been returned. R21's guardian had given consent in 2019.
On 08/11/23 at 9:52 AM, V22 (Primary Care Physician - PCP) was asked about R12, R14, and R21's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 11 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
reported behaviors that prompted his decision to initiate treatment with the Depo-Provera injections. V22
stated R21 was at another facility prior to coming to this facility in 2019. V22 stated R21 had problems with
the nurses and when they came to check on him he would do basically say sexually inappropriate
comments to them that escalated to touching. V22 stated as far as he was told it was just towards staff. V22
stated R12 had similar incidents reported by staff. V22 stated R14 also came from a different facility and
had issues there, but from what V22 was told R14 had not really exhibited sexually inappropriate behavior
since being in this facility. V22 stated he believed R14 may have had inappropriate behaviors towards other
residents there and staff were complaining so it was decided to place him on the depo injections here.
When asked the criteria to introduce the Depo injection to the male population, V22 stated it would be
related to sexually inappropriate behaviors that don't stop with staff interventions. V22 said it was just the
male behavior, and the fact that the frontal lobe is basically gone, they act without thinking, and most likely
would continue. V21 stated R12, R14, and R21 cannot mentally understand or retain redirection so it just
happens over and over. When asked if the resident had to be physically/sexually aggressive, violent, or
have behaviors that rise to the level of rape, he stated they did not. When asked about monitoring
testosterone levels, V22 stated that was not necessary because testosterone was not the issue, the issue
was their mental capacity and the inability to be redirected. V22 stated these residents could be on the drug
indefinitely without causing adverse issues, but he could certainly trial a discontinuation of the
Depo-Provera injections and see how it goes.
The Food and Drug Administration (FDA) Highlights for Prescribing Medication (per
https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020246s036lbl.pdf) documents under
Indications and Usage that Depo Provera is a progestin injectable contraceptive indicated only for the
prevention of pregnancy. A black box warning documents that Women who use Depo-Provera
Contraceptive Injection may lose significant bone mineral density. Bone loss is greater with increasing
duration of use and may not be completely reversible and Depo-Provera Contraceptive Injection should not
be used as a long term birth control method (i.e., longer than 2 years) unless other birth control methods
are considered inadequate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 12 of 13
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
146054
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/11/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gallatin Manor
900 West Race Street
Ridgway, IL 62979
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
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.
Residents Affected - Many
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 swatter.
On 8/8/23 at 2:00 PM, R27 who was alert to person, place and time complained about the flies and asked
surveyor to hand her the fly swatter on her chair.
On 08/10/23 at 2:31 PM, R11 who was alert to person, place and time was sitting in his room attempting to
wave three flies from around his face. Two were observed having landed on his face, and one sitting on his
left arm. R11 was asked if this was normal, and he stated, (expletive) yeah, it's all the time.
On 8/10/23 at 3:00 PM, V1 (Administrator) stated that flies are bad this time of year. V1 went on to state
that the pest control company comes once a month, V1 stated that they have fly lights in the facility in
various places, but with the residents going in and out to the front porch that is where the flies come in.
On 08/11/23 at 2:40 PM, R14 who was alert to person and place was sitting in the hall in his wheelchair
with flies observed buzzing around his head. When asked, R14 stated this did bother him.
The Pest Control Policy documents dated 9/19/19 6. Maintian routine pest control services .
The resident census and conditions of residents dated 8/10/23 document that 34 residents reside in the
facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 13 of 13
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Back to topCitations
16 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.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
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.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the August 11, 2023 survey of GALLATIN MANOR?
This was a inspection survey of GALLATIN MANOR on August 11, 2023. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GALLATIN MANOR on August 11, 2023?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to and the facility must promote and facilitate resident self-determination through support o..."
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.