Health inspection·May 16, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review, the facility failed to discontinue a PRN/as needed medication for one resident (R237) of 20 residents reviewed for unnecessary drugs in a sample of 44. Residents Affected - Few Findings include: Facility Pharmaceutical Procedures, revised 1/5/23, documents It is the policy of the facility to review resident's medication on a regular basis in order to provide residents with only the necessary medication for their health needs. Facility Behavior Management Committee, revised 6/1/22, documents To ensure that each residents medication regimen is free of unnecessary medications. R237's current May 2025 physician orders documents Alprazolam 0.5 mg/milligrams tablet twice a day PRN for generalized anxiety with an order date of 3/12/25. R237's medical record documents the last time R237 received Alprazolam was on 4/9/25. On 5/15/25 at 2:45 PM, V2 DON/Director of Nursing verified R237's medical record had Alprazolam ordered PRN and needed to be discontinued. Page 1 of 8 145598 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a Care Plan to include a blood thinner and Insulin for one resident (R235) of 20 residents reviewed for Care Plan development in a total sample of 44. Findings include: Facility Care Plan Policy, revised 6/1/22, documents It is the policy of this facility to develop a Comprehensive Person-Centered Care Plan as appropriate for each resident to meet a residents medical and nursing needs. R235's May 2025 Physician Orders include orders for Eliquis 5 mg/milligrams twice a day for Atrial Fibrillation, and Humalog Insulin per sliding scale four times a day for Diabetes. R235's May 2025 Medication Administration Record/MAR documents R235 is currently receiving his Eliquis and Humalog Insulin. R235's current Care Plan for May 2025 does not include R235's Atrial Fibrillation diagnosis or Eliquis, and does not include R235's diagnosis for Diabetes or Insulin. On 5/15/25 at 1:35 PM, V13 Care Plan Coordinator stated if the Eliquis and Atrial Fibrillation along with the Insulin and Diabetes was not on the Care Plan then she missed it. At that same time, V13 verified R235's Care Plan did not include the Insulin and Diabetes diagnosis or Eliquis and Atrial Fibrillation diagnosis and should. 145598 Page 2 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to apply leg compression stockings for one resident (R69) of one residents reviewed for compression stockings in a sample of 44. Residents Affected - Few Findings include: Facility Staff Nurse job description, revised 6/2012, documents Responsible for working in a team approach with the nurse aides to ensure residents are receiving said services. Prepares and documents treatments which are administered to residents as prescribed by the residents physician. R69's May 2025 Physician orders documents Tubi Grips (compression stockings) BLE/bilateral lower extremities on in the AM, and off at HS/bedtime. R69's May 2025 Treatment Administration Record documents R69 has her Tubi Grips on. On 5/15/25 at 1:35 PM, R69 was up in the activity area with her bilateral pant legs pulled up with no Tubi Grips, socks, or shoes on. At that same time, V11 CNA/Certified Nurse Aid stated they got R69 up today, are responsible for putting on R69's Tubi Grips, and verified R69 did not have on her Tubi Grips and should have them on her legs. V11 then went to R69's room and verified R69's Tubi Grips were in her top dresser drawer for use. 145598 Page 3 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to identify potential triggers, triggers for a past trauma-related incident, or emotional support needed for one resident (R237) of one resident reviewed for trauma informed care in a sample of 44. Residents Affected - Few Findings include: Facility Social Services Director policy, revised 9/2019, documents Provide social support for residents as needed. Assist with mood and behavior programming processes as needed. R237's medical record documents the following diagnoses: Generalized Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Major Depressive Disorder, and Hallucinations. R237's Social Assessment, dated 3/18/25, documents When a young child (R237's) parents separated and she went into an orphanage for awhile. Eventually, (R237's) parents got back together and took her back, then forced her to go back to school when she didn't want to. R237 was also Sexually Assaulted and experienced a Tornado. This form does not document any potential triggers or emotional support needed for R237. R237's current Care Plan for May 2025 and medical record does not document R237's potential triggers or emotional support needed for her past trauma. On 5/15/25 at 1:25 PM, V12 Discharge Planner stated social services was off work this week but confirmed (R237's) Care Plan and medical record did not address (R237's) potential triggers, or emotional support needed to prevent re-trauma. On 5/15/25 at 4:04 PM, V7 Administrator sent an email to indicate the facility did not have a policy on trauma informed care. 145598 Page 4 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct quarterly QAPI/Quality Assessment Plan Improvement meetings. This has the potential to affect all 97 residents living in the facility. Residents Affected - Many Findings include: Facility QAPI Plan, dated 3/31/25, documents The Committee is responsible for meeting on a quarterly basis. Facility provided QAA sign in sheets dated 3/6/25 and 4/24/25. No other QAA sign in sheets were available to review after the previous survey date of 8/7/24. On 5/13/25 at 12:53PM, V1 Administrator provided two QAA sign in sheets for the past year of QAA meetings. At that same time, V1 stated she cannot find any QAA sign in sheets prior to March 2025. V1 stated when V1 temporarily left in July 2024, QA meetings were not being held in her absence. Centers for Medicare and Medicaid Services (CMS) form 671 Long-term Care Facility Application for Medicare and Medicaid, dated 5/13/2025, signed by V1, document 97 residents reside in the facility. 145598 Page 5 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to identify, monitor and review antibiotic use for five of five residents (R25, R40, R47, R74, R297) reviewed for antibiotic stewardship in the sample of 44 residents. This failure has the potential to affect all residents who reside in the facility with a current census of 97 residents. Residents Affected - Many Findings include: The Infection Control policy revised 12/17/19 documents the Infection Control Committee shall be responsible for surveillance or known nursing home potential infections, the review and analysis of actual infections, the promotion of a preventative and corrective program designed to minimize infection hazards. Follow the Antibiotic Stewardship Program and develop a practical system of reporting, evaluating and keeping records of infections in order to provide an indication of an outbreak level of nosocomial infections and trace the source. The Infection Control Committee reviews the system for reporting, evaluation and keeping records of infections among residents in order to provide an indication of the endemic level of all nosocomial infections to trace the source of infection and to identify epidemic or potential epidemic situations. Nursing staff will develop weekly reports on antibiotics including a review to ensure appropriate use of antibiotics. The Antibiotic Stewardship policy revised 12/18/19 documents the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. The facility will track antibiotic use daily. The facility will ensure the pharmacy reviews all antibiotic usage appropriateness. Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/13/2025, signed by V1/Administrator, document 97 residents reside in the facility. 1. R25's Medication Administration Record (MAR) dated May 2025 documents Macrodantin (antibiotic) was ordered on 9/24/24 for a Urinary Tract Infection and continues to be administered daily. R25's Progress Note dated 9/18/24 documents a response to an inquiry regarding the stop date of the antibiotic made on 9/17/24 was that the antibiotic was a maintenance dose for a history of Urinary Tract Infections and no stop date was ordered. The Infection Tracking Log dated January, February, March, April and May 2025 did not include R25's antibiotic or indication for use. The Pharmacist's Summary of Recommendations dated January, February, March, April and May 2025 did not include an evaluation for R25's Macrodantin prophylactic antibiotic appropriateness. 2. R40's Medication Administration Record (MAR) dated May 2025 documents Macrobid (antibiotic) was ordered on 2/21/25 for preventative use for Urinary Tract Infections and was administered daily until discontinued on 5/15/25. The MAR documents Levofloxacin (antibiotic) was ordered on 5/12/25 - 5/14/25 and 5/15/25 - 5/21/25 for a Urinary Tract Infection. R40's Progress Note dated 12/2/24 documents R40's physician ordered Macrobid daily for preventative use for frequent Urinary Tract Infections. 145598 Page 6 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The Infection Tracking Log dated February, March, April and May 2025 did not include R40's Macrobid antibiotic or indication for use. The Infection Tracking Log documents R40 had a Urinary Tract Infection on 5/10/25 and 5/15/25 and indicated a Culture, Laboratory Test or Radiology Exam was conducted although did not identify the test results/organism (results of the culture) and/or appropriateness of the antibiotic. The Pharmacist's Summary of Recommendations dated March, April and May 2025 did not include an evaluation for R40's Macrobid antibiotic appropriateness. 3. The Pharmacist's Summary of Recommendations dated March 2025 documents an evaluation of R47's Cephalexin (antibiotic) 3/6/25 - 3/13/25 for a diagnosis of Cough. The Infection Tracking Log dated March, April and May 2025 did not include an entry for R47's infection. 4. R74's Progress Note dated 3/20/25 documents to obtain a urinalysis and start Keflex for seven days until urine culture and sensitivity results come back; and 3/22/25 documents to start Cipro for three days for Pseudomonas Aeruginosa. The Infection Tracking Log dated March 2025 indicated a Culture, Laboratory Test or a Radiology Exam was conducted although did not identify the test results/organism and/or the appropriateness of the antibiotic nor the antibiotic ordered on 3/31/25. The Pharmacist's Summary of Recommendations dated March, April and May 2025 did not include an evaluation for R74's Keflex or Cipro antibiotic appropriateness. 5. R297's Medication Administration Record (MAR) dated April 2025 documents Fluconazole (antifungal) was ordered 4/4/25 - 4/9/25 for a rash and nonspecific skin eruption; Azithromycin (antibiotic) was ordered 4/10/25 - 4/14/25 for Atelectasis; Cefpodoxime (antibiotic) 4/15/25 - 4/19/25 for Acute Cystitis; and Levofloxacin (antibiotic) 4/21/25 - 4/27/25 for Acute Cystitis. R297's Progress Note documents on 4/4/25 Fluconazole (anti-fungal) was ordered for four days due to redness and tenderness in the peri-area; on 4/10/25 received order for Azithromycin (antibiotic) received per chest x-ray results; on 4/13/25 completed antibiotic for Pneumonia; on 4/14/25 a new order for Vantin/Cefpodoxime (antibiotic) was ordered for Acute Cystitis; on 4/18/25 remains on antibiotics for Upper Respiratory Infection; on 4/24/25 was treated for a Urinary Tract Infection for Extended Spectrum Beta-Lactamase (ESBL/antibiotic resistant bacteria/organism); and on 4/25/25 a chest x-ray was conducted. The Infection Tracking Log dated April 2025 documents on 4/10/25 and 4/14/25 a Culture, Laboratory Test and/or Radiology Exam was conducted although did not identify the test results/organisms nor the antifungal on 4/6/25 and antibiotic ordered for treatment on 4/10/25. The Pharmacist's Summary of Recommendations dated April and May 2025 did not include an evaluation for R297's antifungal or Levofloxacin appropriateness. On 5/15/25 at 1:30 PM, V3 (Assistant Director of Nursing/Infection Preventionist) stated she only reviews and monitors residents on prophylactic antibiotics when they are first initiated and does not continue monitoring. V3 agreed the Infection Tracking Log did not track the Culture, Laboratory 145598 Page 7 of 8 145598 05/16/2025 Seminary Manor 2345 North Seminary Street Galesburg, IL 61401

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Test or Radiology Exam results, the log was not complete and the Pharmacist's Summary of Recommendations was not inclusive of all antibiotics or antifungals ordered. V3 agreed tracking the source of infections to identify epidemic or potential epidemic situations was not being conducted. On 5/15/25 at 2:15 PM, V1 (Administrator) stated the Infection Prevention Program has struggled with getting the required infection information in the new tracking system and ensuring it's accuracy. 145598 Page 8 of 8