Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gallatin Manor during CMS and state inspections, most recent first.
Failure to Provide Required Written Discharge Notice: A resident with severe cognitive impairment and multiple complex diagnoses was discharged after the facility searched for placement and arranged transfer to another facility, but there was no evidence that the resident's representative or the Ombudsman received the required 30-day written notice. Staff stated referrals were sent and placement was found, but the SS Director did not contact the family or document the upcoming transfer, and the family reported learning of the move only when the receiving facility called shortly before arrival.
Improper Food Storage and Inadequate Dish Sanitizing: During a kitchen observation, two cups of frozen ice cream were found uncovered and unlabeled in the freezer, and a tray of beverages was uncovered and not dated/timed in the reach-in refrigerator. The dish machine had no sanitizer registering on the test strip, yet it was still being used, and later the 3-compartment sink also showed no sanitizer on quat strips until a new solution was mixed. The Dietary Mgr stated that refrigerated and frozen items should be covered, labeled, and dated.
A resident with CVA-related diagnoses and limited ability to be understood was not properly managed for smoking safety. The resident’s chart lacked a current smoking evaluation, the care plan only addressed scheduled smoke times with general supervision, and staff observed the resident smoking in clothing with multiple burn holes while holding the cigarette so the lit end was near the resident’s body and wheelchair cushion. The RDO stated the IDT should complete quarterly smoking assessments and have safe-smoking interventions in place.
The facility failed to maintain accurate records and proper administration of controlled substances for multiple residents, with missing Controlled Substance Proof of Use forms and inconsistent documentation between the eMAR and inventory records. Staff interviews revealed incomplete or delayed documentation, and several narcotic medication deliveries were not properly tracked or reconciled, resulting in significant gaps in accountability.
A resident with chronic pain and multiple medical conditions did not receive prescribed fentanyl patches for several days due to a change in order and lack of medication supply. The DON confirmed the pharmacy had not delivered the new dose, and an RN identified errors in the eMAR administration dates, resulting in missed doses. Facility policy requiring administration of medications as ordered was not followed.
The facility failed to offer pneumonia vaccinations according to CDC guidelines for five residents with various health conditions, including diabetes and chronic obstructive pulmonary disease. Documentation was lacking for offering appropriate vaccines or recording refusals. The facility's policy also did not include updated information on the PCV21 vaccine.
A resident with chronic kidney disease and severe cognitive impairment had an abnormal urinalysis indicating a potential urinary tract infection. Despite the lab results showing positive nitrates and elevated white blood cell count, there was no follow-up or treatment documented. Interviews revealed that the facility staff failed to ensure the physician addressed the abnormal findings, leading to a deficiency.
A resident with PTSD, schizophrenia, anxiety, and dementia did not receive an individualized care plan for PTSD in a facility. Despite reporting flashbacks and nightmares, staff did not track symptoms or monitor medication effectiveness. The DON acknowledged the lack of a care plan, and the facility had no PTSD care policy.
Failure to Provide Required Written Discharge Notice
Penalty
Summary
The facility failed to provide advance written notice of discharge for one resident who was discharged from the facility without evidence that the resident or the resident's representative received the required 30-day notice. The resident's record showed an admission date of 01/13/23 and multiple diagnoses, including disorder of urea cycle metabolism, cirrhosis of the liver, dysphagia, muscle weakness, cognitive communication deficit, anxiety disorder, seizures, schizoaffective disorder, and dependence on a wheelchair. The resident's MDS dated 11/10/25 documented a BIMS score of 01, indicating severe cognitive impairment, and the admission record identified the family member as the responsible party. The resident's Admission/Discharge report dated 11/24/25 documented discharge from the facility on 11/10/25. The Administrator stated the resident had a POA making decisions for her and that the family wanted the resident closer for visits if her care needs could be met. The Regional Administrator stated the facility had been looking for placement for approximately a year and a half and had sent referrals to several facilities until the resident was accepted at a facility that was closer to the family. The Social Services Director stated she sent referrals to potential facilities and confirmed receipt, but she did not contact the family or send them information about the transfer, and she did not document phone calls or the upcoming transfer in the resident's progress notes. The Ombudsman stated she did not receive a discharge notice before the resident's discharge, and the family stated she did not know the resident was being transferred until the receiving facility called her shortly before arrival. The family also stated it had been at least a month and a half since the facility had discussed transferring the resident. The resident's medical record did not include evidence that a 30-day written notice of transfer was provided to the family or the Ombudsman. The facility policy required written notice to the resident and representative, notice to the Ombudsman, documentation of the reasons for transfer or discharge, and inclusion of appeal rights and discharge planning information.
Improper Food Storage and Inadequate Dish Sanitizing
Penalty
Summary
The facility failed to ensure dishes and utensils were properly washed and sanitized, and failed to ensure food and drinks were covered and dated to prevent cross contamination. During the initial kitchen walk-through on 9/16/25, two cups of frozen ice cream were observed uncovered and not labeled in the freezer, and a tray of beverages was found in the reach-in refrigerator without being covered or dated/timed. At the same time, the dish machine had no sanitizer registering on the chlorine test strip. The Dietary staff member stated she had not been able to get sanitizer to register on the strip that morning and said the dish machine had been having issues for over a week while being worked on to get the sanitizer to dispense properly. She also stated the dish machine was still being used that morning even though no sanitizer was registering on the test strip. During a follow-up kitchen visit later that morning, staff were using the three-compartment sink to wash, rinse, and sanitize dishes. When asked to check the sanitizer level in the sink, the Dietary staff member provided quat test strips and two strips showed no sanitizer registering. She then made a new sanitizing solution and checked it until it was within the recommended range. She stated that the machine mixes the solution into the water that runs into the sink and that there is no water fill line, so the sink is filled to what staff think is appropriate and then checked with a strip. The Dietary Manager later stated that all items should be covered, labeled, and dated in the refrigerator and freezer, and that when the dish machine does not work or sanitize, staff should use the three-compartment sink.
Failure to Ensure Safe Smoking Supervision
Penalty
Summary
The facility failed to ensure the safety of 1 of 2 residents reviewed for smoking. The resident had an admission record documenting diagnoses including cerebral infarction, expressive language disorder, and dysphagia following cerebral infarction. The resident’s MDS indicated the resident was rarely or never understood. The EMR showed no smoking evaluation assessment since a 7/8/24 assessment, which documented that the resident had no prior smoking safety issues, was able to safely handle lit smoking materials, did not have burn holes in clothing, did not wear a smoking apron, and did not need one. The care plan identified the resident as a smoker and included only a scheduled smoke-time intervention with general supervision. On observation, the resident’s jacket hanging in the room had multiple burn holes, and the resident was later observed outside smoking while wearing that jacket and pajama pants with multiple burn holes. The resident was given two cigarettes by staff and held the cigarette with the ignited end closest to the palm of the hand. When the resident lowered the cigarette, the ignited end was positioned toward the resident’s body and clothing, and the cigarette was observed almost touching the resident’s pants and bumping the plastic cushion of the wheelchair. The Regional Director of Operations stated the IDT should complete a smoking assessment quarterly and that the resident should have interventions in place for safe smoking, and said he was not sure why interventions were not in place given the burn holes in the resident’s clothing. The facility’s smoking policy stated each resident should be individually assessed for safe smoking, including whether a smoking apron is required, and that the determination should be documented in the care plan and smoking log.
Failure to Maintain Accurate Controlled Substance Records and Administration
Penalty
Summary
The facility failed to maintain accurate records and proper administration of controlled substances for four out of five residents reviewed. Multiple discrepancies were identified between the Electronic Medication Administration Record (eMAR) and the Controlled Substance Proof of Use forms, with several forms missing entirely for various narcotic medications, including fentanyl patches, hydrocodone-acetaminophen, oxycodone-acetaminophen, and morphine. Staff interviews revealed that documentation was often incomplete or not performed in a timely manner, particularly on the eMAR, and that the Proof of Use forms were not consistently filed or scanned into the residents' electronic medical records. For one resident with complex medical needs, including Parkinson's disease and chronic pain, there were lapses in the administration of fentanyl patches due to pharmacy delivery delays and errors in order entry, resulting in missed doses over several days. Additionally, the Proof of Use forms for hydrocodone-acetaminophen were missing, and the number of tablets administered did not consistently match the records. Staff admitted to not always documenting PRN medication administration on the eMAR, relying instead on the Proof of Use forms, which were also not reliably maintained or stored. Similar issues were found for other residents with orders for controlled substances. For example, one resident with pain and muscle spasm diagnoses had multiple deliveries of oxycodone-acetaminophen with missing Proof of Use forms and inconsistent documentation between the eMAR and inventory forms. Another resident with dementia and a history of falls had missing forms for morphine deliveries, and the number of doses administered did not align across records. The facility's policies required accurate documentation and inventory of controlled substances, but these procedures were not followed, leading to significant gaps in accountability and recordkeeping.
Failure to Administer Ordered Narcotic Pain Medication
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's disease, chronic pain syndrome, and systemic inflammatory response syndrome, did not receive narcotic pain medication as ordered. The resident's care plan included administration of pain medication as prescribed by the physician. However, a change in the fentanyl patch order from 12 mcg/hr to 25 mcg/hr was made, but the facility did not have the 25 mcg/hr patches available. As a result, the resident did not receive any fentanyl patch from 4/17/25 through 4/21/25. The electronic medication administration record (eMAR) reflected this gap, and staff noted the absence of the medication during this period. The Director of Nursing confirmed that the pharmacy had not delivered the required medication, and the Registered Nurse identified that the administration dates were incorrect in the electronic record, leading to the missed doses. The facility's policy requires medications to be administered according to physician orders, but this was not followed due to the unavailability of the prescribed medication and lack of timely communication with the medical provider to address the issue. The resident was observed to be non-interviewable due to confusion at the time of the survey.
Failure to Offer Pneumonia Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumonia vaccinations were offered in accordance with CDC recommendations for five residents reviewed for immunizations. The deficiency was identified through interviews and record reviews, revealing that the facility did not have documentation to show that residents were offered the appropriate pneumococcal vaccines or any documentation of refusal. This issue affected residents with various medical conditions, including diabetes mellitus, malignant neoplasm, chronic obstructive pulmonary disease, and heart failure. Resident 25, who had type 2 diabetes mellitus and a malignant neoplasm, received the PCV13 vaccine in 2014 but was not documented as having been offered another pneumococcal vaccine afterward. Similarly, Resident 12, with type 2 diabetes mellitus, received the PPSV23 vaccine in 2015, but there was no documentation of being offered another vaccine. Resident 26, with multiple health conditions including chronic obstructive pulmonary disease, had no record of receiving any pneumonia vaccinations. Resident 4, with a history of pneumonia and heart failure, had received both PCV13 and PPSV23 vaccines but lacked documentation of being offered further vaccination options as per CDC guidelines. Resident 8, with chronic obstructive pulmonary disease and prediabetes, had records of receiving pneumonia vaccines but without specific details on the types administered. The facility's policy did not include updated information regarding the PCV21 vaccine, which is an option in the current CDC guidelines.
Failure to Follow Up on Abnormal Urinalysis
Penalty
Summary
The facility failed to provide appropriate follow-up treatment and services for a resident with an abnormal urinalysis, which indicated a potential urinary tract infection. The resident, who was admitted with a diagnosis of chronic kidney disease and had a severe cognitive impairment, was always incontinent of bladder. A physician's note ordered a urinalysis due to the resident's increased behaviors and insomnia. The urinalysis results showed abnormal findings, including positive nitrates, elevated white blood cell count, and many bacteria, suggesting a possible infection. However, there was no documentation of follow-up or treatment orders in the resident's medical record. Interviews with facility staff revealed that the abnormal urinalysis results were not followed up on, and there was no documentation of any physician's orders addressing the lab findings. The Director of Nursing, who also served as the infection prevention nurse, was unable to locate any follow-up documentation or orders for antibiotics. The Licensed Practical Nurse stated that lab results are typically faxed to the doctor for review and orders, but in this case, the physician's office confirmed receiving the results without any subsequent action. This lack of follow-up and documentation led to the deficiency identified by the surveyors.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to develop an individualized plan of care for a resident diagnosed with PTSD, schizophrenia, anxiety, and dementia. The resident, a war veteran, reported experiencing flashbacks and nightmares due to PTSD, but the staff did not provide any specific interventions to address these symptoms. Despite being prescribed Prazosin for PTSD, there was no plan in place to monitor the effectiveness of the medication or track the resident's symptoms. Interviews with staff revealed a lack of awareness and action regarding the resident's PTSD symptoms, with no tracking or monitoring being conducted. The Director of Nursing acknowledged that the Interdisciplinary Team should have developed a care plan for the resident's PTSD but had not done so. Additionally, the Social Service Director confirmed that while other behavioral issues were being tracked, PTSD symptoms were not. The facility administrator admitted that there was no policy in place for PTSD care, highlighting a systemic oversight in addressing the mental health needs of residents with PTSD.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ridgway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eldorado Rehab & Healthcare | 9.7 mi | ★★★★★ | 1 | 0 |
| Saline Care Nursing & Rehab | 16 mi | ★★★★★ | 0 | 0 |
| Axiom Healthcare Of Harrisburg | 16.4 mi | ★★★★★ | 5 | 0 |
| Wabash Senior Living & Rehab | 20.5 mi | ★★★★★ | 10 | 1 |
| White County Rehab And Nursing | 20.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.