Health inspection·January 3, 2024

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately notify the physician to obtain a treatment for a UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTI's in the sample of three. These failures resulted in R1's UTI being left untreated for 12 days and R1 experiencing increased moaning, pain, and discomfort. This resulted in R1 being sent to the emergency room and admitted to the local hospital for four days to receive treatment with intravenous antibiotics for the diagnosis of Sepsis secondary to a UTI. Findings include: The facility's Lab/Diagnostics Policy dated 11-28-17 documents, Policy: It is a policy of the facility to provide means of quality diagnostic lab services for the residents. Purpose: To provide residents a means of diagnostic service promptly and conveniently. Procedure: 1.Provision for Diagnostic Services: d. Any abnormal lab results upon receipt by the facility nurse will be promptly reported to the to the ordering Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist. Any new orders received as a result will be referred to on the lab slip, orders and in the nurse's notes; g. the lab result will have on it the ordering Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist's name, date and time and the notifying Facility Nurse's signature. The facility's Change in a Resident's Condition Policy dated 12/02 documents, Purpose: Our facility shall promptly notify the resident, and/or resident's representative, and his or her attending physician of changes in the resident's condition and/or status. Procedure: 1. The nurse will notify the resident's attending physician when: b. There is a significant change in the resident's physical, mental, or psychosocial status; e. Deemed necessary or appropriate in the best interest of the resident. On 1-2-24 at 10:03 AM R1's door had a sign indicating R1 was in contact/droplet precautions. R1 was lying in bed with the head of bed raised. R1 was grimacing in pain holding her stomach and stated she needed to use the bathroom. R1 had a brief on, her pants were around her ankles, and R1 appeared restless. R1's current Face Sheet documents R1 has the following diagnoses: Dysuria, Retention of Urine, and UTI. R1's BIMS (Brief Interview of Mental Status) dated 1-2-24 documents R1 is severely cognitively impaired. R1's Nurses Note dated 11-21-23 and signed by V7/RN (Registered Nurse) documents, (R1) yelling out, crying and moaning in pain. (R1) reports all over general discomfort, PRN (as needed) tramadol administered this am (morning). R1's Nurses Note dated 11-23-23 and signed by V6/LPN (Licensed Practical Nurse) documents, This nurse (V6) collected the urine specimen that was needed due to dysuria (painful urination). R1's Urinary Culture and Sensitivity final result dated 11-25-23 documents R1 had greater than (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145598 If continuation sheet Page 2 of 4 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 145598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seminary Manor 2345 North Seminary Street Galesburg, IL 61401 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 100,000 CFU (Colony-Forming Units)/ML (Milliliters)/Klebsiella Aerogenes (bacterial infection of the urine). Level of Harm - Actual harm R1's Nurses Notes dated 11-25-23 (date of final urinary culture and sensitivity) through 12-6-23 do not include any documentation of the facility notifying the physician or obtaining a treatment regarding R1's urinary culture and sensitivity results, dated 11-25-23, indicating R1 had a urinary tract infection. Residents Affected - Few R1's Nurses Note dated 12-7-23 and signed by V5/LPN documents, Per (V8/R1's Primary Physician) N.O. (New Order) for Septra-DS (Double Strength/antibiotic) one tab BID (Twice a Day) PO (by mouth) times 10 days for UTI. R1's Nurses Note dated 12-8-23 and signed by V10/LPN documents, (R1) appears anxious- moaning and crying out. When (R1) asked if she is in pain- (R1) points to her stomach and states her hips hurt. PRN Tramadol administered with little effect. Resident refused dinner tonight and would not sit appropriately for staff to assist with eating. PO fluids encouraged. R1's Nurses Note dated 12-9-23 and signed by V10/LPN documents, (R1) started to get restless and agitated at approximately 9:30 AM. (R1) sliding herself down in wheelchair and holding her knees. Appears to be in pain. (R1) stated that she has pain all over. (R1) would not sit in chair to eat lunch and did not have any intake at lunch. (R1) assisted to bed and PRN Tramadol administered. R1's Nurses Note dated 12-9-23 and signed by V10/LPN documents, (R1) up in chair for supper and started moaning and crying out. (R1) sliding down in her wheelchair. (R1) stated that her back is hurting and she has pain all over. (R1) assisted back to bed for comfort. R1's Nurses Note dated 12-9-23 and signed by V7/RN documents, (R1) moaning, crying and thrashing around in bed. Upon entering room (R1) observed with clothing removed, blankets on floor, and water pitcher on floor. (R1) restless. Face red/flushed. Unable to follow commands. (R1) does report generalized discomfort. T (Temperature) 102.2 P (Pulse) 42 O2 (Pulse Oximetry) 87% (percent) RA (Room Air) BP (Blood Pressure) 142/87. PRN tramadol and Tylenol administered. (R1) continues on antibiotic therapy for UTI. (V8) notified with verbal orders received to send (R1) to ER (Emergency Room) for evaluation. R1's Hospital Note dated 12-9-23 documents R1 was admitted to the local hospital to treat Sepsis secondary to UTI with intravenous antibiotics given 12-9-23 through 12-12-23. This same form documents, (R1) is an [AGE] year-old female with a history of UTI, sleep apnea, hypertension, GERD (Gastroesophageal Reflux Disease), Hyperlipidemia, Parkinson's disease with underlying Dementia, Asthma being admitted to (Local Hospital) on 12-9-23 with a chief complaint of altered mental status. (R1) came from (The Facility) where she was diagnosed with a UTI on 11-23-23. Unfortunately, facility lost the paperwork and did not start treatment until 12-7-23. In the ER (R1) was noted to be septic and sepsis protocol was started. On 1-2-24 at 11:15 AM V4 (Infection Preventionist) stated, (R1) had a history of UTI's. (R1) started to have dysuria on 11-23-23 and we got orders to obtain a UA. The UA final culture came back to the facility on [DATE] as (R1) having a UTI with greater than 100,000 colonies of Klebsiella (bacteria of the urine). There is no documentation of the physician being notified or a treatment order being obtained for (R1's) UTI from 11-25-23 through 12-6-23. The physician should have been notified immediately on 11-25-23 to obtain an order to treat (R1's) UTI. I do not know how it slipped through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145598 If continuation sheet Page 3 of 4 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 145598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Seminary Manor 2345 North Seminary Street Galesburg, IL 61401 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 cracks. On 12-7-23 (V8) called the facility and ordered Septra DS to treat (R1's) UTI. Level of Harm - Actual harm On 1-2-24 at 11:30 AM V8 (R1's Primary Physician) stated, When the facility got (R1's) final UA culture results on 11-25-23, I should have been notified of the results immediately so I could have given an order to start (R1) on antibiotics immediately for a UTI. I am available 24 hours a day, seven days a week. The nurses could have called me anytime to report (R1's) UA results. I noticed (R1) had a UTI according to the UA culture on 12-7-23 and called the nursing home immediately to give an order to start (R1) on Bactrim DS (Septra DS) to treat (R1's) UTI. (R1's) UTI should have been treated immediately on 11-25-23. I cannot deny that if (R1's) UTI was treated immediately it would have kept (R1) from developing further symptoms, becoming septic, and needing hospitalization to treat (R1's) urinary sepsis. The problem is continuity of care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145598 If continuation sheet Page 4 of 4