Health inspection·November 26, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview and record review the facility failed to provide notification in advance of discharge for one (R1) of 4 residents reviewed for notification of discharge in a sample of 4. Findings include:R1's admission record documents an admission date of 01/13/23 with diagnoses including: disorder of urea cycle metabolism, cirrhosis of the liver, disorder of urea cycle metabolism, fatigue, dysphagia, muscle weakness, lack of coordination, history of falling, long term drug therapy, hypotension, personal history of traumatic brain injury, cognitive communication deficit, anxiety disorder, seizures, vitamin B12 deficiency, anemia, estrapyramidal and movement disorder, insomnia, schizoaffective disorder, accidental poisoning by amphetamines, vitamin D deficiency, dependence on wheelchair, abnormal posture, and muscle wasting and atrophy. R1's admission record documents V5 (Family) as R1's responsible party. R1's MDS (Minimum Data Set) dated 11/10/25 documents R1 has a brief interview of mental status (BIMS) of 01 indicating severe cognition impairment. R1's Admission/Discharge to/from report dated 11/24/25, documents R1 was discharged from the facility on 11/10/25.On 11/24/25 at 10:20 AM, V1 (Administrator) stated he believes R1's brief interview of mental status was one or two indicating she was severely cognitively impaired. V1 stated, R1 had a POA (power of attorney) that made her decisions for her. V1 stated, V5 (Family) wanted R1 closer to her to visit if her care needs could be met. V1 stated, they did not document in R1's electronic health record when referrals were sent for R1. V1 stated they did not document in R1's health record when they attempted to contact V5. On 11/24/25 at 1:40 PM, V2 (Regional Administrator) stated he has been looking for placement for R1 for approximately a year and a half. V2 stated, the discussion started when V5 wanted R1 closer, but then we discussed what services she wanted for R1 so we expanded the search to include other facilities that were not necessarily closer but had the services she wanted due to R1's younger age and diagnoses. V2 stated, after sending referrals to several facilities and either being denied or that facility was full, R1 was finally accepted at a facility they felt she would fit well at and it was closer to V5. V2 stated, they accepted the referral and transferred R1.On 11/24/25 at 2:50 PM, V6 (Ombudsman) stated she did not receive a notice of discharge for R1 prior to her discharge. V6 stated, she spoke with V5 and V5 told her she did not know R1 was being transferred before she was transferred and wanted to know if she knew anything about that.On 11/24/25 at 5:18 PM, V5 (Family) stated she did not know they were transferring R1 to (new facility name). V5 stated, she was unaware R1 was accepted at a new facility until V4 (receiving facility Social Services Director) called her to tell her she needed to sign some paperwork because R1 would be arriving at the facility in approximately 30 minutes. V5 stated, it had been at least a month and a half ago since the facility had discussed with her about transferring R1 to a new facility.On 11/25/25 at 10:42 AM, V3 (Social Services Director) stated, when she does a referral she sends the resident's information to the potential facility then she contacts the facility to make sure they have received the information. V3 stated, she did not get into contact with V5 (Family) or send her the information. V3 Page 1 of 2 146054 146054 11/26/2025 Gallatin Manor 900 West Race Street Ridgway, IL 62979

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, she did talk to V5 on 11/07/25 and they did not discuss the discharge to the new facility. V3 stated, she did not document any phone calls to V5 or document anything about the upcoming transfer in R1's progress notes. V3 stated, she failed to do the documentation that she would typically do. On 11/25/25 at 3:30 PM, V4 (receiving facility Social Services Director) stated V5 told her she did not know R1 was coming to (facility name) until she (V4) called her to discuss V5 coming to discuss signing the admission paperwork. R1's medical record did not include evidence that a 30-day written notice of transfer was provided to V5 or V6. The facility policy dated 2025 documents: Notice before transfer: before the facility transfers or discharges a resident, the facility shall; notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, send a copy of the notice to a representative of the office of the state long term care ombudsman. The facility shall maintain evidence that the notice was sent to the ombudsman, record the reasons for the transfer or discharge in the resident's medical record in accordance with this policy and procedure. The contents of the notice; the written notice shall include the following, the reason for transfer or discharge, the effective date of transfer or discharge, the specific location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including the name of the entity which receives such requests and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address and telephone number of the office of the state long-term care ombudsman. Timing of the notice: except as specified in section IV (C)(b) below and except in cases of facility closure, the notice of transfer or discharge required shall be made by the facility as least 30 days before the resident is to be transferred or discharged . Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation shall be discussed with the resident or resident's representative. Discharge summary; when the facility anticipates discharging a resident, the resident shall have a discharge summary that includes, but is not limited to the following: a post discharge plan of care that is developed with the participation of the resident and , with the resident's consent, the resident representative, which will assist the resident to adjust to his or her new living environment. The post discharge plan of care shall indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up and care and any post-discharge medical and non-medical services. 146054 Page 2 of 2