Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide appropriate treatment and services to follow up on
an abnormal urinalysis for 1 (R7) of 1 resident reviewed for urinary tract infections in a sample of 24.
Findings include:
R7's Face Sheet documented an admission date of 04/29/2019 and included a diagnosis of chronic kidney
disease.
R7's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 00 out
of 15 total, which indicates a severe impairment. R7's MDS further documents in section h-bowel and
bladder, that R7 is always incontinent of bladder.
A Physician's Note dated 03/01/2024, found in the miscellaneous tab of R7's medical record, documents
that R7 was having an increase in behaviors and insomnia. This same physician's note documents an order
for a CBC (complete blood count), BMP (basic metabolic panel), and a UA (urinalysis) and C&S (culture
and sensitivity).
R7's Progress Notes document on 03/03/2024 Resident straight cathed (sic) via sterile technique with
immediate return of cloudy dark yellow urine. UA (Urinalysis) specimen collected and taken to (local)
hospital lab. There is no other documentation in the progress notes related to this lab.
A urinalysis for R7, dated 03/03/2024 at 07:32pm documents the following abnormal findings; positive for
nitrates, slightly cloudy, [NAME] Blood cell count of 11-20 (normal range is less than 5), and many bacteria.
The culture and sensitivity for the same above date lists sensitivities to 20 different antibiotics that could
possibly treat the bacteria in R7's urine.
On 09/12/2024 at 12:49 PM, V1 (Administrator) stated, if a urinalysis is done, it would not go on the
infection tracking log unless it was treated. V1 stated, if there was no follow-up or orders received from the
doctor on a pending urinalysis, someone should follow-up and it would be the infection prevention nurse. V1
stated he would still expect to see documentation in the resident's medical record that the doctor addressed
an abnormal lab, even if there were no new orders.
09/11/2024 at 12:28 PMm, V2 (Director of Nursing/DON) stated that the Director of Nursing is the infection
prevention nurse. V2 stated she was not employed here on 03/03/2024, but that she would try her best to
locate the follow-up documentation to the UA results from 03/03/2024. She stated, she would expect to see
some follow-up and/or antibiotics ordered on a lab like that.
(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 7
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
09/12/2024
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 09/11/2024 at 02:30 PM, V2 (DON) stated she was still having issues locating any follow-up
documentation from 03/03/2024.
On 09/12/2024 at 10:36 AM, V8 (Licensed Practical Nurse/LPN) stated, when they received lab results, it
comes over as a fax, they are then supposed to send the fax to the doctor to review and write orders if they
need to.
On 09/12/2024 at 10:55 AM, V2 stated, she had contacted the primary Physician yesterday and they could
see where they had received the lab results from 03/03/2024, but there was no documentation of follow-up,
or any orders given. V2 stated, the physician's office was unsure why it had not been addressed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 2 of 7
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
09/12/2024
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 0742
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental
disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress
disorder.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop an individualized plan of care for the treatment of
PTSD (Post traumatic Stress Disorder) for 1 of 1 (R13) residents reviewed for mental health services in a
sample of 24.
Findings included:
On 9/9/2024 at 10:30 AM, R13 stated he was a war veteran and had PTSD (Post Traumatic Stress
Disorder). R13 said that due to his PTSD, he suffers from flash backs. R13 said when he reports having
issues with flash backs the staff does not really do anything to help him.
R13's Face Sheet documented R13 was admitted to this facility on 10/31/2018 with diagnoses of PTSD,
schizophrenia, anxiety and dementia among others. R13's Minimum Data Set (MDS) dated [DATE]
documented R13's has a Brief Interview for Mental Status (BIMS) score of 10, which indicated R13 had
moderate cognitive impairment.
A form in R13's Electronic Health Record (EHR) titled Initial Social History and dated 11/2/2018,
documents R13 was admitted to this facility with the diagnosis of PTSD among others.
A form in R13's EHR titled Psychiatric Evaluation and Consultation dated 8/22/2024 documents that during
this evaluation, R13 reported not sleeping well at night due to getting flashbacks and getting nightmares
every other day and R13 does not want to talk about the memories of his PTSD.
R13's Physician Order Sheet (POS) dated 8/26/2024 documents R13 was prescribed Prazosin 6mg
(milligrams) by mouth every day to treat PTSD.
A review of R13's EHR and Care Pan revealed no plan of care for R13's PTSD. There were no
individualized non-pharmacological interventions listed for the diagnosis of PTSD, nor any plan for
tracking/monitoring of symptoms or the effectiveness of the medication prescribed for R13's PTSD.
On 9/10/2024 at 11:00 AM, V6 (Licensed Practical Nurse/LPN) stated that R13 has reported to her having
flashbacks, but she just encourages him to try to think positively and not to let it get him upset. V6 said as
far as she knows, the staff do not track when R13 has PTSD symptoms.
On 9/11/2024 at 9:15 AM, V10 (Certified Nursing Assistant/CNA) said she was not aware of any tracking of
PTSD symptoms for R13.
On 9/12/2024 at 9:50 AM, V2 (Director of Nursing/DON) said she was aware of R13's diagnosis of PTSD.
V2 said R13's IDT (Interdisciplinary Team) should have developed a plan of care for R13's PTSD but they
had not. V2 said the facility has not been monitoring or tracking R13's PTSD symptoms.
On 9/12/2024 at 12:30 PM, V9 (Social Service Director/SSD) stated the staff are not tracking/monitoring
R13 for PTSD symptoms, but were tracking other behavioral issues not related to PTSD.
On 9/11/2024 at 12:00 PM, V1 (Administrator) stated the facility did not have a policy regarding
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 3 of 7
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
09/12/2024
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 0742
PTSD care.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 4 of 7
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
09/12/2024
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure pneumonia vaccinations were offered in accordance
with Centers for Disease Control and Prevention (CDC) recommendations for five (R4, R8, R12, R25, R26)
of five residents reviewed for immunizations in a sample of 24.
Residents Affected - Some
Findings Include:
1. R25's Face Sheet documents an admission date of 3/15/2022 and documents R25 is [AGE] years old.
R25's Diagnosis Information listed on the Face Sheet included type 2 diabetes mellitus and malignant
neoplasm of unspecified site of unspecified female breast.
R25's facility document titled Clinical-Immunizations documents PCV13 (pneumococcal 13-valent
conjugate vaccine) was administered on 9/29/2014. The facility did not have documentation to show R25
was offered another pneumococcal vaccine after receiving the PCV13 on 09/29/14 nor any documentation
of refusal.
R25's Physician Order Sheet (POS) documents an order of: may administer immunizations per facility
policy with an order date of 03/16/2022.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults greater
than or equal to [AGE] years old, Complete pneumococcal vaccine schedules: If PCV13 was the only
vaccine administered at any age, Option A documents to administer PCV20 (pneumococcal 20-valent
conjugate vaccine) or PCV21 (pneumococcal 21-valent conjugate vaccine) greater than or equal to a year
after; or Option B documents to administer PPSV23 (pneumococcal polysaccharide vaccine) greater than
or equal to a year after. This job aid also documents consider minimum interval (8 weeks) for adults with
immunocompromising condition .
2. R12's Face Sheet documents an admission date of 7/01/2022 and documents R12 is [AGE] years old.
R12's Diagnosis Information listed on the Face Sheet included Type 2 Diabetes Mellitus.
R12's facility document titled Clinical-Immunizations documents PPSV23 was administered on 02/12/2015.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults
19-[AGE] years old with chronic health conditions (which includes Diabetes mellitus), Complete
pneumococcal vaccine schedules: If PPSV23 was the only prior vaccine administered, Option A documents
to administer PCV20 or PCV21 greater than or equal to a year after; or Option B documents to administer
PCV15 (pneumococcal 15-valent conjugate vaccine) greater than or equal to a year after.
R12's POS documents an order of: may administer immunizations per facility policy with an order date of
07/01/22.
The facility did not have documentation to show R12 was offered another pneumococcal vaccine after
receiving the PPSV23 on 02/12/15 nor any documentation of refusal.
3. R26's Face Sheet documents an admission date of 7/28/2022 and documents R26 is [AGE] years old.
R26's Diagnosis Information listed on the Face Sheet included unspecified bacterial pneumonia,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 5 of 7
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
09/12/2024
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
chronic obstructive pulmonary disease, unspecified, hypoxemia, type 2 diabetes mellitus, other viral
pneumonia, acute cough, acute upper respiratory infection, and cannabis use.
R26's Immunization Report does not document administration of any pneumonia vaccinations.
R26's POS documents an order of: may administer immunizations per facility policy with an order date of
07/29/2022.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Adults
19-[AGE] years old with chronic health conditions (which includes Diabetes mellitus and chronic obstructive
pulmonary disease), Complete pneumococcal vaccine schedules: If no prior pneumococcal vaccines have
been administered, Option A documents to administer PCV20 or PCV21; or Option B documents if PCV15
is used, then follow with one dose of PPSV23 greater than or equal to one year later.
The facility did not have documentation to show R26 was offered a pneumococcal vaccine nor any
documentation of refusal.
4. R4's Face Sheet documents an admission date of 11/20/2015 and documents R4 is [AGE] years old.
R4's Diagnosis Information listed on the Face Sheet included pneumonia, unspecified organism, and heart
failure, unspecified.
R4's facility document titled Clinical-Immunizations documents Pneumovax Dose 1 (Manuacturer's Name:
Prevnar 13) was administered on 5/1/2016 and Pneumovax Dose 1 (Manufacturer's Name: Pneumovax 23)
was administered on 5/26/2017.
R4's POS documents an order of: may administer immunizations per facility policy with an order date of
11/19/2019.
The CDC's Pneumococcal Vaccine Timing for Adults job aid documents the following under Shared Clinical
decision-making for those who already completed the series with PCV13 and PPSV23: Together, with the
patient, vaccine providers may choose to administer PCV20 or PCV21 to adults (greater than or equal to)
[AGE] years old who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and
PPSV23 at or after the age of [AGE] years old.
The facility did not have documentation to show whether R4 was offered another pneumococcal vaccine or
if R4's vaccine provider recommended consideration for the PCV20 or PCV21 vaccine for R4.
5. R8's Face Sheet documents an admission date of 10/31/2023 and documents R8 is [AGE] years old.
R8's Diagnosis Information listed on the Face Sheet included chronic obstructive pulmonary disease with
(acute) exacerbation, other specified viral diseases, and prediabetes.
R8's facility document titled Clinical-Immunizations in the electronic health record (EHR) documents
Pneumonia, unspecified on 05/31/2017 and 12/06/2018. R8's State of Illinois Certificate of Child Health
Examination document provided by the facility documents Pneumococcal Conjugate Dose 1 was
administered on 05/31/2017 and Dose 2 was administered on 12/06/2018.
The facility did not have documentation to show what types of pneumonia vaccines were administered to
R8 or any attempts to determine which pneumonia vaccines were administered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 6 of 7
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
09/12/2024
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R8's POS documents an order of: may administer immunizations per facility policy with an order date of
01/05/2024.
On 9/10/24 at 9:54 AM, V2 (Director of Nursing/DON) stated, no pneumonia vaccines have been given
since V2 took over the role a few months ago. V2 stated the pneumonia vaccines should be given per the
CDC and the facility's policy.
The facility document titled, Pneumococcal Vaccination Policy and Procedure dated 10/16/2023 documents
under Procedure: The pneumococcal vaccine is ordered upon admission by the attending physician. If the
vaccine is not ordered, the physician/nurse must document as to reason why not .and documentation in
(the facility's EHR) Immunization tab regarding the administration, type, time, lot, expiration and location of
the pneumonia vaccine administration must be input into the Medication Administration Record, 24 hour
Resident Condition Report and Progress Notes. This policy further documents the CDC recommends
pneumococcal vaccination for adults 19 through [AGE] years old who have certain chronic medical
conditions or other risk factors, including (but not limited to) diabetes mellitus, chronic lung disease,
including chronic obstructive pulmonary disease, generalized malignancy, and cigarette smoking. For those
who have not previously received any pneumococcal vaccine the CDC recommends to give one dose of
PCV15 (Pneumococcal 15-valent Conjugate Vaccine) or PCV20. For those who have only received the
PPSV23, PCV15 vaccination or PCV20 vaccination should be administered at least one year after the most
recent PPSV23 vaccination. For Adults 65 years or older who have only received PPSV23 vaccination the
PCV15 vaccination or PCV20 vaccination should be administered at least one year after the most recent
PPSV23 vaccination. For adults who have received the PCV13, then give the PPSV23 vaccination. If the
PCV15 vaccination is used this should be followed by PPSV23 vaccination one year later.
The facilty's Pneumococcal Vaccination Policy and Procedure does not include any updated information
regarding the PCV21 vaccine that is documented as an option in the current CDC's Pneumococcal Vaccine
Timing for Adults job aid.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146054
If continuation sheet
Page 7 of 7
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Back to topCitations
10 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.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
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.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F742 - Based on the comprehensive assessment of a resident, the facility must
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the September 12, 2024 survey of GALLATIN MANOR?
This was a inspection survey of GALLATIN MANOR on September 12, 2024. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GALLATIN MANOR on September 12, 2024?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arra..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.