Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 2 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to develop and implement pressure relieving
interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk
assessment once a week for four weeks after admission, obtain a treatment for a newly identified pressure
ulcer, and accurately and thoroughly assess pressure ulcers weekly for two of three residents (R1 and R2)
reviewed for facility acquired pressure ulcers in the sample of five. These failures resulted in R1 developing
an unstageable pressure ulcer to the left heel six days after admission to the facility and R2 developing a
stage three pressure ulcer to the right heel and an unstageable pressure ulcer to the inner ankle that
required autolytic debridement (using own body's enzymes to remove dead tissue) and caused R2 severe
pain.
Residents Affected - Few
Findings include:
The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol dated 10-24-22 documents
Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide
guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury
refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or
related to a medical or other device. A pressure injury will present as intact skin and may be painful. A
pressure injury will present as an open ulcer. The appearance of which will vary depending on the stage
and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in
combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin
temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Principles: 1.
A skin assessment is completed on all residents upon admission and weekly for the first four weeks after
admission, quarterly, and whenever there is a change in the resident's condition. 2. An individualized plan of
care will be developed for the resident following the guidelines of the assessment. 3. All high and moderate
risk residents will be assessed for the needs of the items below. If the intervention is initiated, it will be
added to the care plan. A. Special mattress and wheelchair cushions. B. PROMS (Passive Range of
Motions). C. Protein and/or Nutritional Supplements. D. Turning and positioning schedule. E. Skin Checks. F.
Elbow/heel protectors/bridging of heels. 6. When a resident is admitted to the facility or develops a pressure
injury in the facility, the following will occur: A. Assess the pressure injury for location, size, wound bed,
drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissues, and pain at site. B.
Determine the injury's current stage of development: Stage One Pressure Injury: Non-blanchable erythema
of intact skin. Stage Two Pressure Ulcer: Partial thickness skin loss with exposed dermis, presenting as a
shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or
ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not viable. Granulation
tissue, slough, and eschar are not present. Stage Three Pressure Ulcer: Full thickness loss of skin, in which
subcutaneous fat is visible in the ulcer and
(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 8
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
02/11/2025
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 0686
Level of Harm - Actual harm
Residents Affected - Few
granulation tissues are epibole (rolled wound edges) are often present. Slough and or/eschar may be
visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an
unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer: Full-thickness ski and tissue loss
in which the extent of tissue damage with the ulcer cannot be confirmed because the wound bed is
obscured by slough or eschar. Stable eschar (dry, adherent, intact without erythema or fluctuance) should
only be removed after careful consideration and consultation with the resident's physician, or nurse
practitioner, physician assistant, or clinical nurse specialist. Deep Tissue Pressure Injury: Persistent
non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue, this
area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to
adjacent tissue, This injury results from intense and/or prolonged pressure and shear forces at the
bone-muscle interface. C. Notify the physician of the above assessment and obtain orders for treatment of
pressure ulcer/injury. If pressure ulcer/injury is showing no improvement, Physician will be notified so
change of treatment may be obtained, E. Care plan will be established for treatment of existing pressure
ulcers/injuries. G. For pressure ulcer with drainage the physician will be notified, and culture obtained if
ordered. Pressure Injury and Treatment Protocol: H. Weekly measurements will be conducted and entered
in the chart under wound management. J. Turning and repositioning assistance will be given to those
residents that are unable to reposition themselves. K. Special devices will be used to relieve pressure, L. All
treatment and charting of pressure ulcers/injuries will be done by licensed staff.
R1's admission Record documents R1 was a [AGE] year-old admitted to the facility on [DATE] with the
diagnoses of a Left Femur Fracture, Abnormalities of Gait and Mobility, Lack of Coordination, and
Weakness.
R1's Procedure and Surgeon Notes dated 12-2-24 document R1 received a left hip open reduction internal
fixation with intramedullary implant repair to repair R1's left hip fracture.
R1's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) and 12-31-24
document R1 was at risk of developing a pressure ulcer.
R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 was cognitively intact and had no
pressure ulcers on admission [DATE]). This same MDS Assessment documents R1 developed a facility
acquired stage II pressure ulcer.
R1's Medical Record does not include evidence of a Braden Scale being completed every week for four
weeks after R1's admission, as instructed by the facility's Pressure Injury/Pressure Ulcer Prevention and
Treatment Protocol.
R1's Progress Notes dated 12-11-24 and signed by V5 (Prior Director of Nursing) document, While
dressing (R1) for the day (CNA/Certified Nursing Assistant) notified this nurse of area to (R1's) left heel.
Area is a 3.5 cm (centimeter) by 3.7 cm fluid filled blister, not draining, surrounded by pink normal skin.
Area cleansed, skin prepped, and border foam applied for protection. Foot floated while CNA finished
dressing (R1). Recommendation to continue above treatment and apply moon boot forwarded to (Clinic).
R1's Hospital Discharge summary dated [DATE] documents, (R1) was noted to have a left heel blackish
blister upon admission (hospital admission [DATE]). Likely 2/2 deep tissue injury (full-thickness deep tissue
injury) causing some localized bleeding resulting in a blood blister. ABI (Ankle-Brachial Index) normal to left
lower extremity.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 2 of 8
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
02/11/2025
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 0686
Level of Harm - Actual harm
R1's Progress Notes dated 1-12-25 and signed by V6 (Wound Nurse) document, (R1's) wound
measurement area to (R1's) L (left) heel. Area is a 4 cm x 5 cm fluid filled blister, not draining, surrounded
by pink normal skin. Area cleansed, skin prepped, and border foam applied for protection. Foot floated while
CNA finishes dressing (R1).
Residents Affected - Few
The facility's Weekly Wound Reports dated 12-18-24, 12-25-24, and 1-8-25 document R1's wound to the
left heel as a stage one Pressure Injury.
The facility's Weekly Wound Report and R1's Medical Record/Progress Notes do not include a weekly
assessment of R1's wound to the right heel for the week of 1-1-25 through 1-7-25.
R1's Care Plan dated 12-5-24 (Admission) through 1-14-25 (Discharge) documents, Problem: (R1) is at
increased risk for pressure ulcers related to decreased mobility and generalized muscle weakness following
recent illness and hospitalization. Goal: (R1) will have decreased risk for skin breakdown during this
quarter. Interventions: Assist (R1) with turning and re-positioning. Pressure reducing device in wheelchair
and bed. Provide incontinence care after each incontinent episode. Therapy as ordered. This same care
plan does not include R1's new onset of a pressure ulcer to the left heel with goals or interventions to treat
and prevent the left heel pressure ulcer from declining or prevent further pressure ulcer development.
R1's Progress Notes dated 1-15-25 document R1 was discharged to another long-term care facility per the
family's request.
On 1-28-25 at 9:37 AM V8 (R1's Family Member) stated, Anytime I would visit (R1) when she was admitted
to the facility, she would not have a heel boot on.
On 1-29-25 at 9:10 AM R1 was living in another long-term care facility and was interviewed by phone. R1
stated, I broke my right hip and could not move my leg on my own while in bed. I could not feel my heels at
all due to the swelling. The staff never elevated my feet off the bed, and I did not get those jelly filled (heel
protection) boots until after I got the sore to my left heel. I did not wear shoes while in bed or while in the
recliner. When I was in the recliner my heels would be lying on the footrest.
On 1-29-25 at 9:45 AM V6 (Wound Nurse) stated, I categorized (R1's) left heel pressure ulcer as a stage
one throughout (R1's) stay here. I did not know if a pressure ulcer was black or purple that it was
considered unstageable. I have not had a lot of wound training. There were a lot of staff off around
Christmas, so no wounds got assessed from 12-25-24 through 1-7-25.
On 1-29-25 at 1:50 PM V16 (Care Plan Coordinator) stated, I am sorry. I am behind a month on care plans.
(R1's) Care Plan was never updated to include pressure relieving interventions to prevent pressure ulcers
to (R1's) heels and was never updated once (R1) developed a new pressure ulcer to the left heel with goals
to prevent the pressure ulcer from worsening and prevent further pressure ulcers.
On 1-29-25 at 2:10 PM V7 (Nurse Practitioner) stated, (R1's) pressure ulcer to the left heel was probably
caused by pressure when (R1) would be sitting in her recliner. When sitting in the recliner, (R1's) heels
would by lying on the footrest.
On 1-29-25 at 2:18 PM V15 (Prior DON/Director of Nursing) stated, (R1) was in bed quite a bit and did not
have a wound to her heel on admission. (R1's) heels would be on the bed and that is what
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 3 of 8
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
02/11/2025
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 0686
Level of Harm - Actual harm
Residents Affected - Few
caused the pressure ulcer to (R1's) right heel. (R1) had a broken left hip. On 12-11-24 a CNA found a
wound to (R1's) left heel and reported it to me. I assessed the wound and noted the wound to be a 3.5 cm
by 3.7 cm fluid filled unstageable blister caused by pressure.
On 1-29-25 at 2:30 PM V10 (MDS Coordinator) stated, I am responsible for completing the Braden Scale
Assessments and I have been behind. (R1) was supposed to have a Braden Score completed on
admission and every week for four weeks after admission. (R1) only had a Braden Scale Assessment
completed on admission and did not have one completed for the next three weeks after admission.
On 2-3-25 at 10:00 AM V17 (Therapy Director) stated, When (R1) had admitted here the beginning of
December 2024 (R1's) legs were so heavy from the fluid build-up. (R1) could not lift her legs or feet up off
the bed by herself. (R1) also had groin pain whenever trying to lift her legs up. (R1) needed moderate
assistance of staff to raise her legs and feet off the bed and turn and re-position while in bed.
2. R2's current Physician's Orders document R2 has the diagnoses of Chronic Congestive Heart Failure
and Cerebrovascular Disease.
R2's MDS Assessments dated 11-25-24 and 12-5-24 document R2 is severely cognitively impaired and
had no pressure ulcers.
R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) documents R2
was not at risk of developing pressure ulcers.
R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents R2 was at high
risk of developing pressure ulcers.
R2's Care Plan dated 11-18-24 (re-admission to facility) through 12-12-24 (date of pressure ulcer
development to right heel) does not include pressure ulcer relieving interventions to prevent pressure ulcer
development once R2 was identified by the Braden Scale for Predicting Pressure Sore Risk Assessment
(dated 11-18-24) as being at high risk of developing pressure ulcers.
R2's Event Details and Progress Notes dated 12-12-24 and signed by V6 (Wound Nurse) documents,
Pressure Injury to Right Heel. Orders: Right heel cleanse area, apply Medi-honey and mepilex to be
changed daily. (R2) has an area on his right heel that measures by 5 cm x 4 cm.
R2's Medical Record dated 12-12-24 only includes a measurement of R2's newly developed right heel
pressure ulcer and does not include any further description of the pressure ulcer's wound bed, drainage,
odor, tunneling, undermining or sinus tract, or wound edges/surrounding tissues.
The facility's Weekly Wound Report and R2's Medical Record/Progress Notes do not include a weekly
assessment of R2's wound to the right heel for the week of 1-1-25 through 1-7-25.
R2's Wound Management Progress Notes dated 1-22-25 and signed by V6 document, (R2) has an area on
his right heel that measures 2.4 cm by 3.4 cm and an area to his right medial ankle measuring at 2.4 cm by
2.0 cm. Both have serosanguinous (drainage of blood and serum) drainage between minimal and
moderate. Both Stage II.
R2's Medical Record does not include documentation of V4 (R2's Physician) being notified of R2's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 4 of 8
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
02/11/2025
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 0686
pressure ulcers having drainage or an order to treat the newly developed pressure ulcer to R2's right inner
ankle on 1-22-25.
Level of Harm - Actual harm
Residents Affected - Few
R2's Physician's Order and Treatment Administration Records dated 1-22-25 through 2-4-25 do not include
a physician's order to treat R2's right inner ankle pressure ulcer or evidence of a treatment being performed
to R2's right inner ankle pressure ulcer.
R2's Wound Visit Notes dated 2-5-25 and signed by V19 (Clinical Wound Care Nurse) document, Wound
Right, Medial Heel is a Stage Three Pressure Ulcer acquired on 12-12-24 and had received a status of not
healed. Initial wound encounter measurements are 2 cm length by 1.2 cm width, by 0.3 cm depth. There is
a moderate amount of drainage noted. Wound bed had 76-100 percent granulation (healing tissue), 1-25
percent slough (dead tissue). Debridement Performed: Autolytic. Wound Right, Medial Ankle is an
Unstageable Pressure Injury obscured full-thickness skin and tissue loss. Pressure ulcer acquired on
1-22-25 and had received a status of non-healed. Initial wound measurements are 2 cm length by 1.5 cm
width by 0.3 cm depth. There is a moderate amount of serous drainage noted. Wound bed had 1-25 percent
granulation, 76-100 percent slough, Debridement performed: Autolytic.
On 1-29-25 at 9:50 AM R2 was lying in bed with a cushioned heel protecting boot to R2's right foot. R2's left
foot was lying directly on the bed. R2 had an uncovered pressure ulcer to the right inner ankle and a
dressing dated 1-28-25 to the right heel. V6 (Wound Nurse) removed the dressing to R2's right heel and
measured both pressure ulcers to R2's right heel and right inner ankle. R2's right inner ankle pressure ulcer
measured 2.3 cm by 2.7 cm and was covered in 100 percent slough with a moderate amount of
serosanguinous drainage. R2's right heel pressure ulcer measured 1.6 cm x 2 cm with 50 percent
granulation tissue and a moderate amount of serosanguinous drainage. V6 proceeded to cleanse both
pressure ulcer with normal saline, applied Medi honey, and covered with gauze. During the treatment R2
was hollering out in pain stating, My foot hurts! My foot hurts!
On 1-29-25 at 10:00 AM V6 (Wound Nurse) stated, I noticed (R2) had a new pressure ulcer to the right
inner ankle last week (1-22-25). The right inner ankle wound had drainage last week but did not look this
bad and I do not remember the wound having slough last week. (R2) usually always has pain when I
change his dressings. I do not recall if the physician was notified of (R2's) wounds to the right heel and right
inner ankle having drainage. I have caterogorized both of (R2's) pressure ulcers to the right foot and right
inner ankle as stage two's.
On 2-10-25 at 9:20 AM V6 stated, There is no documentation of a treatment order being obtained to (R2's)
right ankle pressure ulcer or documentation of a treatment being performed to (R2's) right ankle pressure
ulcer on (R2's) treatment administration record.
On 2-10-25 at 11:00 AM V4 (Physician) stated, Both of (R1) and (R2) heels should have had off-loading to
prevent the pressure ulcers from developing. That is basic to prevent pressure ulcers. Around three months
ago the wound nurse was very active there about letting me know if there were changes to wounds. For the
past three months I have not had a lot of communication with the facility about the residents' pressure
ulcers. (R1's) pressure ulcer should not have been categorized as a stage one. (R1's) pressure ulcer to the
heel would have been an unstageable pressure ulcer. (R2's) pressure ulcer to the right inner ankle should
have been categorized as unstageable.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 5 of 8
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
02/11/2025
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
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few
Based on record review and interview, the facility failed to monitor the level of Oxygen in a portable Oxygen
tank for a resident diagnosed with Congestive Heart Failure, ensure a continuous Oxygen supply was
administered as ordered by the Physician, and failed to perform an assessment after a resident went
without Oxygen and experienced respiratory distress and a low pulse oximetry reading for one of three
residents (R1) reviewed for Oxygen use in the sample of five. These failures resulted in R1 being without
oxygen for 20 minutes on one occurrence and 10 minutes on second occurrence, which caused R1 to
experience chest pain, shortness of breath, feelings of being smothered and imminent death.
Findings include:
The facility's Oxygen Therapy and Safety policy dated 4-9-20 documents Area: Nursing. It is the policy of
this facility to provide a safe environment for residents, staff, and the public. Purpose: To provide a source of
oxygen to persons experiencing an insufficient supply of same and to address the use and storage of
oxygen and oxygen equipment. Staff responsible: Director of Nursing, Staff Nurse, Nurse Aides. Oxygen
Therapy: M.D. (Medical Doctor) will provide: When to use, how often, liter flow, and whether to use cannula
or mask. Document date, time, flow rate, frequency, and results of oxygen therapy in medical record.
Address use of oxygen in care plan. Oxygen in Use: Licensed staff using oxygen equipment will be trained
in its operation, safety precautions, and manufacturer's instructions for using equipment.
R1's admission Record documents R1 was a [AGE] year-old admitted to the facility on [DATE] with the
diagnoses of a Congestive Heart Failure, Weakness, Chronic Obstructive Pulmonary Disease, Acute and
Chronic Respiratory Failure with Hypoxia, Dependence on supplemental oxygen, Atrial Fibrillation, and
Chronic Fatigue.
R1's MDS (Minimum Data Set) Assessment documents R1 was cognitively intact.
R1's Physician's Orders dated 12-5-25 through 12-7-24 document, Oxygen at five liters per nasal cannula
continuously for Shortness of Breath.
R1's Physician's Orders dated 12-7-25 through 12-23-24 document, Oxygen at four liters per nasal cannula
continuously for Shortness of Breath. Oxygen Saturation every shift-titrate oxygen to maintain above or
equal to 90% (percent).
R1's Physician's Orders dated 1-3-25 through 1-10-25 document, Oxygen at five liters per nasal cannula
continuously.
R1's Physician's Order dated 1-10-25 and signed by V14 (Pulmonologist) document, Keep (R1) at six liters
of oxygen. May titrate to keep oxygen saturation above 89%.
R1's Nephrology Physician's Progress Notes dated 1-6-25 and signed by V8 (R1's Nephrologist)
documents, (R1) has not been brought in with her required amount of supplemental oxygen with oxygen
saturations around 80 percent.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 6 of 8
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
02/11/2025
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
R1's Care Plan from admission [DATE]) to discharge (1-14-25) does not address R1's oxygen needs or
goals.
Level of Harm - Actual harm
Residents Affected - Few
R1's Progress Notes do not include any documentation of an assessment performed after R1 went without
oxygen on 1-6-25 or any other occurrences of R1 going without her physician ordered oxygen.
R1's Progress Notes dated 1-15-25 document R1 was discharged to another long-term care facility per the
family's request.
On 1-28-25 at 9:37 AM V13 (R1's Family Member) stated, On 1-6-25 I met (R1) and (V12/Transport) at
(V8's) office. Upon arrival, I questioned how much oxygen was available. The driver (V12) replied they had
one oxygen unit. I expressed this was inadequate for (R1's) needs. (V12) told me to call if (R1) needed
more oxygen. When in (V8's) office I noticed (R1's) oxygen tank was empty. The staff came in and (R1's)
pulse oximetry was 80 percent and (R1) was cyanotic, slurring her words, and complaining of back and arm
pain. (V8's) instructions were to take(R1) to prompt care. (V8's) secretary stated that she had called (V12)
and was told (V12) was filling an oxygen tank right then. From the time (V8's) secretary called for more
oxygen to when (V12) came with the oxygen was 20 minutes. During dinner on 1-12-25 (R1's) oxygen tank
again went empty. It was empty for more than ten minutes. (R1) started to become symptomatic. Another
resident's family member (V9) noticed (R1) in distress and went to get a nurse. The nurse returned without
an oxygen tank. After what was described as what seemed like a long time an unknown CNA returned with
a replacement oxygen tank. No vital signs were recorded in (R1's) medical record and no progress or
assessment was made about the occurrence. I was scared for (R1's) life while she was at that facility, and
we decided to move (R1) to a different facility.
On 1-28-25 at 2:15 PM V12 (Transport) stated, I am not certified. On 1-6-25 I took (R1) to her appointment
with (V8). (V13/R1's Family Member) road with me in the van to the appointment. I took one portable
oxygen tank with us to the appointment. (V13) told me I should take two tanks. I spoke to a nurse, and she
told me I only needed one oxygen tank. I do not remember what nurse I spoke to. I filled (R1's) tank before
the appointment. I dropped (R1) off for her appointment and went back to the facility. Around an hour to an
hour and a half later, I got a call from the receptionist at (V8's) office saying I needed to get to their office
fast because (R1) ran out of oxygen and was having a hard time breathing. I got a new oxygen tank and
went to (V8's) office. (V13) was outside and waiting on me. I disconnected (R1's) oxygen tubing from the
empty tank and attached the oxygen to the new tank. I turned the dial to five liters as that is what (V8) said
(R1) needed. I brought (R1) back to the facility and a CNA took (R1) to her room. Some of the portable
oxygen tank's gauges do not work.
On 1-29-25 at 9:10 AM R1 was living in another long-term care facility and was interviewed by phone. R1
stated, I ran out of oxygen three or four times while living at that nursing home (the facility). One time at
suppertime, I started to feel funny and checked my oxygen tubing. No oxygen was coming out. No staff
were in the dining room, so I asked a visitor who was in there to go get me help. I felt like I was going to
pass out and started having chest pain. It is the worst feeling when you cannot breathe. I was short of
breath and felt like I was being smothered. It felt like forever before someone got me an oxygen tank. I was
lucky the visitor was there to help me. When I went to the doctor (1-6-25) I was in the office and my oxygen
tank ran out. I started turning purple and my eyes were twitching. I had chest pain. My son (V13) kept telling
me to deep breath. I don't know what it feels like to die, but I know I felt close to it that day. It took 30
minutes for the facility to get me oxygen. The staff did not make sure I always had oxygen.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 7 of 8
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
02/11/2025
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 - Actual harm
Residents Affected - Few
On 1-29-25 at 10:40 AM V9 (Visitor) stated, I was in a private dining room on 1-12-25 with my parents and
another resident (R1). (R1) was the only other resident in this dining room. There were no staff present in
this dining room. (R1) told me, I need help! (R1) was panicked and having a hard time breathing. I went and
found a staff member and told them (R1) needed oxygen. (R1) was trying to deep breath and it looked like
(R1) was struggling to breath. It took a nurse around ten minutes to get (R1) oxygen. It really scared me.
On 1-29-25 at 11:05 AM V20 (Oxygen Supply Company Representative) stated, The portable oxygen tanks
are older and some of the gauges do not work properly and the tanks do not have the volume to fill
completely, making them not last as long as they should. If a patient is on five liter of oxygen, an oxygen
concentrator should really be used to prevent a patient from running out of oxygen.
On 1-29-25 at 2:10 PM V7 (Nurse Practitioner) stated, (R1) should not have run out of oxygen with her
diagnoses. Running out of oxygen would cause (R1) to become short of breath and her pulse oximetry to
drop. (R1) should have been on an oxygen concentrator and not on a portable oxygen tank.
On 1-29-25 at 2:18 PM V15 (Prior DON/Director of Nursing) stated, I was not aware of (R1) running out of
oxygen or experiencing shortness of breath or other symptoms from running out of oxygen. If (R1) went
without oxygen a nurse should have done an assessment of (R1) and documented the occurrence in (R1's)
progress notes.
On 1-29-25 at 2:40 PM V21 (CNA/Certified Nursing Assistant) stated, We (facility staff) really do not have a
set schedule on when to check residents to make sure their oxygen tanks are full. I just check periodically,
and if the oxygen tanks are empty I fill them. The portable oxygen tanks do not last long.
On 1-30-25 at 11:55 AM V14 (Pulmonologist) stated, I saw (R1) in my office and (R1) was very upset and
said she ran out of oxygen several times. (R1) is [AGE] years old and requires supplemental oxygen at all
times. (R1) has multiple heart concerns and has Chronic Obstructive Pulmonary Disease, Valvular Heart
Disease, and Congestive Heart Failure. At absolutely no time should (R1) have ran out of oxygen. There is
no excuse that the facility could have for (R1) to go without oxygen at any time. Any amount of time that
(R1) would go without oxygen could result in (R1's) oxygen levels dropping and would be devastating and
detrimental to (R1's) health. It could result in (R1's) death. (R1's) oxygen saturations should never drop
below 89 percent.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145598
If continuation sheet
Page 8 of 8
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 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.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 February 11, 2025 survey of SEMINARY MANOR?
This was a inspection survey of SEMINARY MANOR on February 11, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SEMINARY MANOR on February 11, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.