Inspection·April 30, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were treated with dignity and respect for 2 of 5 residents (R2 and R3) reviewed for resident rights in the sample of 5. The findings include: 1. On 4/30/24 at 11:20 AM, R2 said that she had an issue with V3 (Registered Nurse) two Sundays ago. R2 said that the new person in the room next to her was having her family bring in a rug and she didn't feel that that was appropriate due to being a trip hazard. R2 said that V3 came to give her with evening medications and she questioned her about the rug and V3 turned bright red, put her hand up in my face to gesture stop and said very loudly, I don't know who gave them permission, it's not your concern. She was not speaking to me in a very dignified manner and I didn't appreciate it. All she had to say is I'm not sure but I will look into it and move on. R2's Minimum Data Set assessment dated [DATE] shows that her cognition is intact. 2. On 4/30/24 at 12:15 PM, R3 said that she has had issue with V3 in the past but she has gotten better. R3 said that V3 had came into her room and asked her a question and she responded, No. V3 then said to her in a very loud voice, Don't talk to me that way. R3 said that V3 was just not very nice and did not treat her with respect. R3 said, She (V3) turns really quickly and I don't know why. R3's Minimum Data Set assessment dated [DATE] shows that her cognition is intact. On 4/30/24 at 2:44 PM, V1 (Administrator) said that all residents should be treated with dignity and respect at all times. The Facility's Resident's Rights for People in Long-Term Care Brochure that is provided to the upon admission shows, You have the right to safety and good care .The facility must provide services to keep your physical and mental health and sense of satisfaction. 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 3 Event ID: 146140 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 146140 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Galena Stauss Nursing Home 215 Summit Street Galena, IL 61036 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)