Health inspection·January 31, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to reasonably accommodate one of three Residents (R1) reviewed for Resident cares in a sample of three. Residents Affected - Few Findings include: Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: you have the right to make your own choices; your Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; the Facility must provide equal access to quality care regardless of diagnosis condition or payment source; the Facility must provide services to keep your physical and mental health, at their highest practical levels; and you have the right to complain to your Facility. R1's current Care Plan, documents that R1 admitted to the facility on [DATE]. R1's Care Plan also documents diagnoses including: Urinary Tract Infection, Congestive Heart Failure, Dyspnea, Weakness, Need for Assistance for Personal Care, Muscle Weakness, Abnormal Gait and Mobility, Pain and Anxiety; R1 is on Hospice Care; and that R1 requires substantial maximum assistance of one staff member for bed mobility and transfers. R1's Minimum Data Set/MDS, Section GG (Functional Abilities and Goals) dated 10/21/23, documents that R1 requires partial to moderate staff assistance with lying and sitting on the bed. The Facility local State Agency Report (State of Illinois/Illinois Department of Public Health), dated 12/22/23, documents an incident with R1 and V3 (Certified Nursing Assistant/CNA). The Report documents that R1 stated that V3 (CNA) was upset with R1 for requesting that the R1 asked the girls to boost me up in the bed and they did but then I slid back down so I had to call them again and I could tell she (V3) was upset. R1 stated that V3 (CNA) told R1 that they cannot just keep coming in here every two minutes to help you. R1 stated that V3's (CNA's) attitude needed to be addressed. The Facility local State Agency Report (State of Illinois/Illinois Department of Public Health), dated 12/22/23, documents V3 (CNA) stated way before dinner time, V3 Told (R1) that (R1) would stop sliding down in bed if (R1) kept (R1's) knees up and would be easier because she was on top of everything and could not help scoot (R1) up. R1 also stated, that was the third time I had boosted (R1) up in 20 minutes and I told (R1) that it was getting harder for me to pull (R1) up because I was losing strength and that I had been here since 5:30 am. (R1) got mad because I asked (R1) to help as much as (R1) could when rolling and (R1) yelled at me. I asked (R1) to please not yell at me. (R1) got nasty with me and was telling me I needed to do a bunch of things and I told her that I was getting to them one at a time. I told (R1) that I understood (R1's) pain. I asked (R1) what was going on with (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: 145598 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 01/31/2024 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)