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 (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 2 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 11/26/2025 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)