Seminary Manor: Hip Fracture After Staff Left Resident Alone - IL
The fall happened on September 9, 2025. The certified nursing assistant, identified in the inspection report as V6, told investigators she had walked the resident, referred to as R2, from just outside the bathroom, fitted her with a gait belt, set her on the toilet, and left. She walked to another hallway and was standing there charting when she heard a yell.
By the time V6 reached the room, a licensed practical nurse was already inside. R2 was on her back on the bathroom floor, her walker pinned under her legs, her gait belt still around her waist. She had a gash across the bridge of her nose. Her glasses were still on her face. There was a laceration to her forehead and another to her right upper arm. Her right leg had visible external rotation. She was conscious and talking, and she was complaining of a lot of pain.
911 was called. Emergency medical workers slid a sling under R2 and lifted her onto a stretcher by hand.
At the hospital, CT scans told the rest of the story. A CT of her head showed scalp contusions. A CT of her facial bones showed contusions and hematomas across her face. A CT angiogram of her chest found a contusion and hematoma over her right collarbone and nondisplaced fractures of the posterior 8th and 9th ribs on her left side. The hospital admission record also noted a laceration to her right forehead, skin tears to her left knuckle and right elbow, an abrasion on her chin, and bruising and swelling over her right clavicle. By the time she arrived at the emergency room, she had also sustained a closed fracture of her left hip. She was admitted.
R2 spent more than a week in the hospital. She returned to Seminary Manor on September 16.
The following morning, a surveyor found her in a wheelchair in her room. The bruising had spread across her entire face, her neck, her hairline, and her visible arms and legs. A laceration on her right forehead was healing. She was alert and answered questions without difficulty.
"I'm in so much pain," she said. "They left me in the bathroom. They weren't supposed to, and I fell and broke my ribs. I can't hardly move anymore."
V6 told investigators that R2 had been at the facility for a couple of months and that staff had been encouraging her to do more for herself. R2 had been in therapy, V6 said, and she thought R2 was getting stronger. She acknowledged that her usual practice had been to stay with R2 in the bathroom, or to stand just outside the bathroom door with it cracked open. On September 9, she made a different decision.
"I thought she would be okay if I walked away," V6 said.
The Director of Nurses, identified as V2, confirmed to investigators that R2 required extensive staff assistance for toileting. V2 also noted that R2 was very anxious and needed frequent staff encouragement just to use the call light when she needed help. After the fall, V2 said, staff updated R2's care plan to specify that she was not to be left alone on the toilet.
The update came after R2 was already on a stretcher.
Federal inspectors cited the facility for a failure to protect residents from accidents under tag F689, finding actual harm affecting a small number of residents. R2 is now non-weight-bearing and non-ambulatory.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seminary Manor from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
SEMINARY MANOR in GALESBURG, IL was cited for violations during a health inspection on September 18, 2025.
The fall happened on September 9, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.