Health inspection·September 18, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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 provide staff supervision during toileting for a resident that was assessed as requiring toileting assistance (R2), one of three residents reviewed for falls, in a sample of 3. This failure resulted in R2 being left unsupervised, falling from a toilet resulting in a head laceration, extensive bruising and fractured ribs. FINDINGS INCLUDE:R2's facility Resident Face Sheet documents that R2 was admitted to the facility on [DATE] with the following diagnoses: History of Falls, Displaced Fracture of Greater Trochanter of Left Femur, Need for Assistance with Personal Care, Weakness, Generalized Anxiety Disorder, Exudative Age-Related Macular Degeneration, right eye, Osteoarthritis, Asthma and Chronic systolic (congestive) heart failure.R2's Hospital History and Physical Transfer Notes document, (R2) has a past medical history significant for congestive heart failure (CHF), a fall, hypertension (HTN), hyperlipidemia, atrial fibrillation (a-fib), urinary incontinence, takotsubo syndrome, macular degeneration, and a history of an anterior wall myocardial infarction (MI) resulting in weakness. The patient fell and sustained a left femur fracture, for which an open reduction and internal fixation (ORIF) procedure was performed. (R2) admitted to Skilled Nursing Facility on 07/17/2025 for skilled nursing and rehab. (R2) asked to be seen by primary team to optimize therapy, pain control and discharge planning. (R2)'s plan and progress were discussed with nursing staff and therapy. Frequent monitoring and management by trained clinicians are essential to safeguard patient well-being, enhance recovery, and prevent clinical decline. The complexities of rehabilitation, chronic conditions, and individualized treatment plans necessitate regular assessments for early detection of complications, frequent adjustments of treatment plans and to promote patient safety. R2 becomes very anxious and starts to panic making her very unsafe at times.R2's Care Plan, dated 7/18/25 includes the following Problem Areas: (R2) is at risk for falling related to recent illness/hospitalization and new environment. (R2) has increased confusion and does attempt to get up (as desired) without using call light, despite numerous education attempts. (R2) has voiced to staff that she does not like to turn her call light on because she doesn't want to bother anyone. (R2) needs encouragement to utilize staff for help.R2's Fall Risk Assessment Tool, dated 7/18/25 documents, (R2) has a history of falls, is incontinent of bowel and bladder, receives opiates, diuretics, hypnotics, sedatives and psychotropic medication and requires assistance for mobility, transfers or ambulation. Score is 17: High Risk for Falls.R2's Occupational Therapy Screen, dated 7/18/25 documents, Toileting hygiene = Substantial/maximal assistance.R2's Minimum Data Set Assessment, dated 7/24/25 documents: Section GG: Toileting Hygiene/admission Performance - The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment: 02- Substantial/Maximal Assistance and Toilet Transfer/admission Performance - The ability to get on and off a toilet or commode: 01-Dependent.R2's Physician Progress Notes, dated 7/21/25 document, (R2) fell (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 09/18/2025 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)