Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
2. 08/04/24 08:00AM R2's oxygen tubing was coiled up on bedside chair and attached to nebulizer machine
dated 5/28.
Residents Affected - Some
3. On 8/4/24 at 8:05 R34's Oxygen tubing and nasal cannula were on the floor in his room with no date on
the oxygen tubing. R34 was not in his room at the time and the tubing was connected to an oxygen tank
inside of his room and it was running.
On 08/04/24 at 8:30 AM R34 was in the dining room with a small oxygen tank on the back of his wheelchair
with oxygen tubing that had no dates on it.
4. On 08/04/24 R62's Oxygen tubing and nasal cannula were on the floor in her room with no date on the
oxygen tubing. R62 was not in her room at the time and the tubing was connected to an oxygen tank inside
of his room and it was running.
On 08/04/24 at 8:30 AM R62 was in the dining room with a small oxygen tank on the back of her wheelchair
with oxygen tubing that had no dates on it.
Based on observation, interview and record review, the facility failed to ensure a nebulizer mask and
nebulizer tubing was changed every seven days and stored in a bag between uses for two residents (R2
and R18) and failed to ensure Oxygen tubing was changed every seven days for two of four residents (R2,
R34, and R62) reviewed for respiratory care in a sample of 30.
Findings include:
The facility's Nebulizer Treatment Administration, dated 01/2003, documents Purpose: 1. For delivery of
liquid aerosol medication, as prescribed by a physician. 2. To aide in expectorations of secretions.
Equipment: 1. Nebulizer unit. (Consists of (1) Medication container, (2) Nebulizer T-piece, and (3)
Mouthpiece.) 2. O2 (Oxygen) tubing. Procedure: 15. O2 tubing used only for intermittent nebulizer therapy
must be changed weekly. If used more often, such as for receiving O2, replace tubing every 48 hours. 16.
Disposable nebulizers must be replaced every 15 days.
The facility's Oxygen Therapy, dated 3/16/17, documents Objective: 1. To provide a source of oxygen to
persons experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing)
must be exchanged every seven days. Documentation: 1. Date, time, flow rate, frequency, and results of
oxygen therapy in Medical Record.
1. R18's current POS (Physician Order Sheet) documents a Physician order for Albuterol Sulfate Solution
0.62 milligram/3 milliliter one vial inhalation orally four times a day as needed.
(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 5
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
08/07/2024
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 8/4/24 at 9:30 AM R18's nebulizer tubing and nebulizer mask was lying on R18's nightstand un-bagged
and dated 6/20/2024.
On 8/4/24 at 9:23 AM V4/Registered Nurse confirmed R18's nebulizer tubing and nebulizer dated 6/20/24
and un-bagged. V4 stated, Nebulizer masks and nebulizer tubing should be changed at least every seven
days and bagged after use.
Event ID:
Facility ID:
145598
If continuation sheet
Page 2 of 5
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
08/07/2024
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review, the facility failed to document justification for the use of duplicative
antidepressant therapy for one of five residents (R18) and failed to document the justification for reinstating
an antipsychotic for one resident (R60) reviewed for psychotropic medications in the sample of thirty.
Findings Include:
The facility's Psychopharmacologic Drug Usage Procedure, dated 10/18/17, documents Definition: A
psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating
psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety
medications, and sedatives/hypnotics. Procedure: Use of psychopharmacological medications requires
assessment by the attending physician, and specific orders must be written by the attending physician with
supporting diagnoses. 2. Psychopharmacological medication usage must be reassessed at least every 90
days and include rationale for continuing the medication. 7. Documentation of behaviors and conditions
requiring the use of these mediations must be done on routine basis, as well as medication response and
adverse consequences.
1.) R60's admission Physician Order Sheet dated 5/10/2021 documents that R60 was admitted to the
facility on the anitpsychotic medication Olanzapine 5 mg (milligrams) every night for Dementia with
Delusions and Agitation.
R60's Medication Regime Review from Pharmacy dated 8/3/23 documents a recommendation for the
doctor to discontinue the use of the antipsychotic medication Olanzapine due to no documented behaviors
to justify the use of it. The Physician accepted the recommendation so the medicine was discontinued.
R60s nurse notes document that on 5/8/24 R60's daughter stated that when (R60) stayed the weekend with
her that she was argumentative with her and accusatory. Daughter states that is what happens when they
try to reduce their medication.
R60's nurse's notes document that on 5/4/24 at 1:40 PM R60 was standing in the front entry telling staff
she was going on a walk she was reminded that she needs staff to assist her that she became agitated with
staff. She offers statements of missing clothing items.
R60's Nurse Notes on 5/4/24-5/29/24 document several episodes of R60 yelling at staff regarding missing
clothing, becoming angry and agitated with staff. There is no documentation of R60 having delusions or
halluciantions.
R60's Physican Order Sheet for June 2024 documents that R60 was put back on antipsychotic medication
Olanzapine 2.5 mg (milligrams) every 12 hours as needed for agitation and delusions.
R60's Physican Order Sheet for June 2024 documents that R60 was put back on antipsychotic medication
Olanzapine at 5 mg every night for failed gradual dose reduction with return of agitation and delusions.
On 8/6/24 at 10:00 AM V3 (Licensed Practical Nurse/ Care Plan Coordinator) confirmed that R60 was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 3 of 5
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
08/07/2024
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
upset about laundry that indeed was missing and some were ruined by the laundry dpartment and replaced
by facility. V3 stated that R60 was obsessed about her missing clothes and was very angry and upset. V3
stated The daughter also wanted her back on her regular dose of medicine.
On 8/6/24 at 10:15 AM V2 (DON) also confirmed that R60's clothes that she accused people of stealing
were missing, that they were at the daughters house after a home visit. V2 also confirmed that the facility
had ruined some of R60's clothes and she became very upset and was yelling at staff. V2 confirmed that
the things that R60 was upset about were actually happening, therefore would not be considered delusions
or hallucination.
2. R18's POS (Physician Order Sheet) documents the following: Mirtazapine (antidepressant) 30mg
(milligrams) by mouth daily, Bupropion HCL (hydrochloride) (antidepressant) 300mg by mouth daily, and
Sertraline (antidepressant) 150mg by mouth daily.
On 8/7/24 at 10:00AM V2/Director of Nursing stated she is the individual responsible for managing
psychotropic medications for the residents in the facility. V2 stated R18 is not a harm not herself or others.
V2 stated she is not sure why R18 is taking three antidepressants, and verified that this information was not
documented in R18's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 4 of 5
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
08/07/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview observation and record review the facility failed to ensure that wound care supplies
were disinfected after each resident's wound cares. This failure has the potential to affect residents (R34,
R57, R62, R67, R80, R199) that receive wound cares in the facility.
Residents Affected - Some
Findings include:
The facility's Standard Precautions policy facility's Wound Care policy, dated 08/2009, documents Standard
Precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat),
non-intact skin, and mucous membranes may contain transmissible infectious agents.
On 08/06/24 at approximately 1:00pm, V2 DON (Directed of Nurses), provided a Wound Summary Report,
dated 08/05/2024, listing residents receiving wound care in the facility.
The facility's Wound Care policy, dated 03/2004, documents, **Standard Precautions Must Be Followed
During Care of Wounds. **
R80's medical record documents diagnoses including Insulin Dependent Diabetes and Chronic Kidney
Disease Stage three. R80's Treatment Administration Record documents. Wound Care to Upper Gluteal
Region: 1) Clean and dry area well. 2) Apply thin layer of zinc paste over open areas. 3.) Place bordered
foam dressing. 4) Change daily and as needed.
R80s Physicians Progress Note by resident's physician (V9), dated 8/5/24, documents under Chief
Complaints: Pressure Ulcer and Assessment includes: Pressure Ulcer Left Buttock. V9 Dr. Wagner's Plan
documents, I would put a moisture barrier this wound followed by a (bordered foam dressing).
On 8/5/24 at approximately. 10:05am, R80 was laying on their left side and R80's waterproof, bordered
dressing, dated 8/4/24, was intact to R80's coccyx and left buttock area.
On 8/5/24 at 10:25am V3, Wound Nurse and ADON, Assisted Director of Nurses, gathered wound supplies
and completed R80's daily wound care as ordered, to include cleansing R80's wound with an eight-ounce
spray bottle of wound cleanser, using spray at close proximity to R80's open wound.
After completion of R80's wound care, V3, ADON, returned wound cleanser spray bottle to the top
treatment cart in the Medication Room without disinfecting the wound cleanser bottle. V3 stated that the
multi-use spray wound cleanser is used for multiple residents' wound cared treatments and returned to the
treatment cart.
On 8/6/24 at 10:45am V6, LPN (Licensed Practical Nurse), verified that spray wound cleanser bottles are
used for multiple residents' wound care and stored in the Medication Room or on the top of the treatment
cart.
On 8/7/24 at approximately 8:30am, V2, DON (Director of Nurses), stated that the wound cleanser bottles
used for wound care throughout the facility, are considered community property and used for multiple
residents' wound cares.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
FAQ · About this visit
Common questions about this visit
What happened during the August 7, 2024 survey of SEMINARY MANOR?
This was a inspection survey of SEMINARY MANOR on August 7, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SEMINARY MANOR on August 7, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.