Health inspection·September 8, 2022

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) action plan to address symptomatic staff to resident COVID-19 outbreaks within the facility. This failure had the potential to affect all 114 residents residing within the facility. Findings include: The CMS (Centers for Medicare & Medicaid Services) Form 672 (Resident Census and Conditions of Residents), dated 8-31-22 and signed by V2 (Director of Nursing), documents 114 residents reside within the facility. The facility's Quality Assurance Performance Improvement policy, dated 2-11-21, documents, The long term care facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of outcomes of care and quality of life. Based on resident interviews, observations, family interviews, or record reviews any issues that are identified as potentially causing harm to the resident will be immediately brought to the attention of the administrator, addressed, and resolved. Performance Improvement Plans (PIPs) may be created for the deficient F Tag responses or area of concerns that require extensive ongoing monitoring. Be sure all areas of the PIP are completed-Definition, Team, Analysis, Measures, Interventions. Document the conclusion of the PIP when completed. The facility's COVID-19 tracking logs, dated 6-1-22 through 8-2-22, document there were numerous resident facility outbreaks of COVID-19 due to staff working directly with residents while having symptoms of COVID-19 throughout this timeframe. On 9/06/22 at 10:30 AM, V3 (Assistant Director of Nursing), stated the facility had discussed the concerns of the outbreak of COVID-19 in the Quality Assurance and Safety meetings monthly, and the concerns of staff not reporting symptoms of COVID-19 and exposing the residents, but the facility never developed a plan or any additional monitoring/training of staff to try to prevent further COVID-19 outbreaks within the facility due to staff working while symptomatic. On 9/06/22 at 10:20 AM, V1 (Administrator) stated, We (the facility) have not developed a QAPI plan to address the COVID-19 outbreak within the facility. The only thing we have done differently was implement staff to wear N95 masks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 2 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's COVID-19 (Coronavirus Disease 2019) Infection Prevention and Control Program policy was followed, failed to screen all staff for COVID-19 symptoms before the start of their scheduled shifts, filed to remove symptomatic employees from work immediately, failed to test and quarantine employees who had symptoms of COVID-19 immediately, and failed isolate residents who were unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. These failure affected 24 of 24 residents (R4, R7, R12, R20, R22, R26, R38, R45, R49, R51, R63, R64, R72, R83, R85, R87, R88, R90, R91, R93, R94, R100, R107, R256) reviewed for COVID-19 infection control procedures in the sample of 60. These failures resulted in numerous symptomatic COVID-19 positive staff working directly with residents, resulting in an outbreak of COVID-19 within the facility and 24 residents developing symptomatic COVID-19 (a severe acute respiratory syndrome). Residents Affected - Some These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9-8-22, the facility remains out of compliance at a severity Level II as the facility continues to screen and audit to ensure employees screen prior to their shift for COVID-19, test employees and residents who are symptomatic for COVID-19 immediately, remove employees from the facility immediately who have symptoms of COVID-19, isolate residents who are not up to date with the COVID-19 vaccination or are unvaccinated and have direct contact with anyone who is COVID-19 positive, in-service staff on the facility's COVID-19 Infection Prevention and Control Program policy, and report audits/findings to the Quality Assurance Committee monthly. Findings include: The facility's COVID-19 Infection Prevention and Control Program policy, dated 3-22-22, documents, Description: (The facility) has developed a COVID-19 infection prevention and control program to decrease the risk of residents and staff becoming infected with SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), the virus that causes COVID-19. Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting, requires aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes. Policy: It is the policy of (the facility) to implement COVID-19 infection prevention and control policies and procedures under the recommendation and guidance of the Centers for Disease Control and Prevention (CDC), (State agency), and the (Local Health Department/ACHD) to decrease the risk of COVID-19 transmission to our residents. Leadership Responsibilities: Administrative LeadershipResponsibilities: to develop, implement, and oversee the facility COVID-19 Infection Prevention and Control policies and procedures, to stay current on changes and updates to any provided guidance from the state and federal governing authorities to delegate facility departmental tasks to adhere to changes in restrictions and infection control precautions, to communicate with ACHD and governing authorities as needed and requested. B. Nursing Leadership- Responsibilities: to oversee and implement COVID-19 Infection Prevention and Control policies and procedures for all direct care staff, to stay current on changes and updates to any provided guidance from the state and federal governing authorities requested, review and store all infection control logs for staff screenings, resident screenings, and infection totals, to ensure an appropriate amount of Personal Protective Equipment (PPE) is available, report infection control information in the daily standup meetings, and as necessary. Testing Plan and Response Strategy: The occurrence and frequency of all future (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 3 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some testing will be based upon the results of facility testing, changes in the surrounding community, and the current requirements of state and federal authorities. All future testing will be completed using a contracted testing laboratory (PCR/Polymerase Chain Reaction testing) and/or point-of-care testing. Although PCR testing remains the gold standard for testing, point-of-care antigen (rapid) testing is acceptable. A. When to test: Symptomatic residents and/or staff regardless of vaccination status (testing should take place immediately.) D. Confirmed Positive Tests: If COVID-19 testing results in positive cases of COVID-19 amongst staff and/or residents, the appropriate protocols will be followed to decrease the spread of illness. All confirmed cases will be reported to ACHD and CDC. Employees- Any employee who tests positive or is suspicious for having COVID-19 will immediately leave the facility and follow the instructions from their medical provider and/or health department. E. Facility Response to a Positive Test (Investigation): Affected Neighborhoods (exposed)- If resident is asymptomatic and not up to date and are considered to be a close contact to the individual who tested positive, room quarantine for 14 days even if testing negative. Staff should wear full PPE (Personal Protective Equipment) when providing care to this resident (N95, eye protection, gown, and gloves). Interventions: Employee Screenings- Employees will need to screen at the beginning of each shift using a checklist-based screening protocol in written format. All symptomatic employees must be immediately removed from the resident area, receive a SARS-CoV-2 rapid test, and sent home. If rapid antigen test is positive, please see confirmed positive tests for employees for further guidance. If rapid antigen test is negative, employee must receive a confirmatory SARS-CoV-2 PCR (Polymerase Chain Reaction) test and will be restricted from work pending result. Screenings will check for COVID-19 infection criteria in accordance with the CDC. Vaccinations and Vaccine Boosters: COVID-19 vaccinations and vaccine boosters will be offered to all consenting and eligible employees and residents onsite at scheduled dates and times through the [NAME] County Health Department. Additional vaccination locations will be shared with employees as they become available. (The facility) will continue to provide educations and promote the vaccination to all staff, residents, and families who are not up to date. The CDC COVID-19 Data Tracker, dated 8-29-22 through 9-6-22, documents COVID-19 Community Level of contracting COVID-19 as High for [NAME] County Illinois (the county the facility is within). The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2-2-22, documents, Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: A positive viral test for SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus Two) symptoms of COVID-19, close contact with someone with SARS-CoV-2 infection, or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2. The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus two) Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities website, dated 2-2-22, documents, Manage residents who had close contact with someone with SARS-CoV-2 Infection: Residents who are not up to date with all recommended COVID-19 (Coronavirus Disease 2019) vaccine doses and who have had close contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 4 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP (Health Care Personnel) caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure if they do not develop symptoms. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure if a viral test is negative for SARS-CoV-2 and they do not develop symptoms. Residents Affected - Some 1. R88's Face Sheet, dated 6-30-22, documents R88 is an [AGE] year-old, with the diagnoses of Dysphagia, Acute Respiratory Disease, Anemia, Hypertension, and Dementia without Behavioral Disturbance. R88's Progress Notes, dated 6-22-22, document, Unit: [NAME] Center. (R88) having symptoms of coughing, clear nasal drainage, and complaints of sore throat, and having weakness. Negative COVID test and us (the facility) sending off a PCR COVID test. Doctor gave orders for Mucinex and Tussin. R88's COVID-19 Antigen Test, dated 6-23-22, documents R88 tested positive for COVID-19. 2. R26's Face Sheet, dated 8-25-16, documents R26 is a [AGE] year-old, with the diagnoses of Alzheimer's Disease, Abnormal Weight Loss, Major Depression, Restlessness and Agitation, and Primary Weakness. R26's COVID-19 Antigen Test, dated 6-26-22, documents R26 tested positive for COVID-19. R26's Progress Notes, dated 6-27-22 at 3:05 PM, document R26 developed symptoms of a runny nose and cough. 3. R91's Face Sheet, dated 10-28-21, documents R91 is a [AGE] year-old, with the diagnoses of Dementia without behavioral disturbance, Muscle Weakness, Congestive Heart Failure, Stage four Chronic Kidney Disease, Anemia, Malignant Neoplasm (Cancer) of the right lung, Type II Diabetes Mellitus, Cardiac Pacemaker, and Obesity. The facility's COVID-19 Positive Log documents R91 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-26-22 of loose stools and malaise, and tested positive for COVID on 6-26-22. R91's COVID-19 Antigen Test, dated 6-26-22, documents R91 tested positive for COVID-19. 4. R20's Face Sheet, dated 3-4-22, documents R20 is a [AGE] year-old, with the diagnoses of Hypertension, Muscle Weakness, Alzheimer's disease, and Cognitive Deficit. The facility's COVID-19 Positive Log documents R20 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-26-22 of a cough and congestion, and tested positive for COVID-19 on 6-26-22. R20's COVID-19 Antigen Test, dated 6-26-22, documents R20 tested positive for COVID-19. 5. R72's Face Sheet, dated 12-13-18, documents R72 is a [AGE] year-old, with the diagnoses of Anemia, Major Depression Dementia with behavioral disturbance, Congestive Heart Failure, Chronic Atrial Fibrillation, and Nutritional Deficiency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 5 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The facilities COVID-19 Positive Log documents R72 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of diarrhea and non-productive cough, and tested positive for COVID-19 on 6-27-22. R72's COVID-19 Antigen Test, dated 6-27-22, documents R72 tested positive for COVID-19. 6. R45's Face Sheet, dated 2-19-18, documents R45 is a [AGE] year-old, with diagnoses of Alzheimer's Disease, Chronic Pain, Anxiety, and Hyperlipidemia. The facilities COVID-19 Positive Log documents R45 resided on the [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of runny nose and non-productive cough, and tested positive for COVID-19 on 6-27.22. R45's COVID-19 Antigen Test, dated 6-27-22, documents R45 tested positive for COVID-19. 7. R7's Face Sheet, dated 1-2-19, documents R7 is a [AGE] year-old, with the diagnoses of Alzheimer's Disease, Anxiety, Fatigue, Dysphagia, Major Depressive Disorder, Chronic Pain, Hypertension, Muscle Weakness, and Cardiac Pacemaker. The facilities COVID-19 Positive Log documents R7 resided on [NAME] Center hallway, and developed symptoms of COVID-19 on 6-27-22 of cough, and tested positive for COVID-19 on 6-27-22. R7's COVID-19 Antigen Test, dated 6-27-22, documents R7 tested positive for COVID-19. 8. R64's Face Sheet, dated 6-16-17, documents R64 is a [AGE] year-old, with the diagnoses of Heart Failure, Muscle Weakness, Anemia, Neuromuscular Dysfunction, Hypertension, and Epilepsy. The facilities COVID-19 Positive Log documents R64 resided on Eastbrook Lane, and tested positive for COVID-19 on 6-27-22. R64's COVID-19 Antigen Test, dated 6-27-22, documents R64 tested positive for COVID-19. 9. R22's Face Sheet, dated 12-08-21, documents R22 is an [AGE] year-old, with diagnoses of Dementia without behavioral disturbance, Parkinson's disease, Hypertension, Cerebral infarction, Mixed Hyperlipidemia, and Lack of coordination. The facilities COVID-19 Positive Log documents R22 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 6-29-22 of body aches, and tested positive for COVID-19 on 6-29-22. R22's COVID-19 Antigen Test, dated 6-29-22, documents R22 tested positive for COVID-19. 10. R107's Face Sheet, dated 7-15-21, documents R107 is an [AGE] year-old, with diagnoses of Anemia, Dementia without behavioral disturbance, Hypertension, Nonrheumatic aortic valve stenosis, and Type 2 Diabetes. The facilities COVID-19 Positive Log documents R107 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-05-22 of cough and sneezing, and tested positive for COVID-19 on 7-05-22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 6 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 R107's COVID-19 Antigen Test, dated 7-05-22, documents R107 tested positive for COVID-19. Level of Harm - Immediate jeopardy to resident health or safety 11. R63's Face Sheet, dated 6-09-22, documents R63 is a [AGE] year-old, with a diagnoses of Hemiplegia and hemiparesis following cerebral infarction affecting right dominating side, Cerebral infarction, Hypertension, Muscle weakness, and Chronic Kidney Disease. Residents Affected - Some The facilities COVID-19 Positive Log documents R63 resided on [NAME] Gardens hallway, and tested positive for COVID-19 on 7-07-22. R63's COVID-19 Antigen test, dated 7-06-22, documents R63 tested positive for COVID-19. 12. R256's Face Sheet, dated 6-22-22, documents R256 is an [AGE] year-old, with diagnoses of Cerebral infarction, Chronic kidney disease, Muscle weakness, Type 2 diabetes mellitus, and Hyperlipidemia. The facilities COVID-19 Positive Log documents R256 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-05-22 of cough and congestion, and tested positive for COVID-19 on 7-07-22. R256's COVID-19 Antigen Test, dated 7-07-22, documents R256 tested positive for COVID-19. 13. R51's Face Sheet, dated 4-20-21, documents R51 is a [AGE] year-old, with diagnoses of Hyperlipidemia, Muscle weakness, Dementia without behavioral disturbance, and Anemia. The facilities COVID-19 Positive Log documents R51 resided on [NAME] Center hallway, and developed symptoms of COVID-19 on 7-05-2022 of being fatigued and confused, and tested positive for COVID-19 on 7-08-2022. R51's COVID-19 Antigen test, dated 7-07-22, documents R51 tested positive for COVID-19. 14. R49's Face Sheet, dated 4-13-21, documents R49 is an [AGE] year-old, with diagnoses of Parkinson disease, Dementia without behavioral disturbance, Muscle weakness, and Polyneuropathy. The facilities COVID-19 Positive Log documents R49 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 7-09-2022 of confusion, runny nose, weakness, and fatigue, and tested positive for COVID-19 on 7-09-22. R49's COVID-19 Antigen Test, dated 7-9-22, documents R49 tested positive for COVID-19. 15. R83's Face Sheet, documents R83 is a [AGE] year-old, with diagnoses of Chronic obstructive pulmonary disease, Dementia without behavioral disturbance, Malignant neoplasm of the breast, Polyneuropathy, Hypertension, Heart failure, and Hyperlipidemia. The facilities COVID-19 Positive Log documents R83 resided on [NAME] hallway, and developed symptoms of COVID-19 on 7-13-2022 of congestion and fever, and tested positive for COVID-19 on 7-14-22. R83's COVID-19 Antigen Test, dated 7-14-22, documents R83 tested positive for COVID-19. 16. R100's Face Sheet, dated 7-15-2021, documents R100 is an [AGE] year-old, with diagnoses of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 7 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Dementia without behavioral disturbance, Type 2 diabetes mellitus, Hypertension, Anemia, Alzheimer's disease, and Hyperlipidemia. The facilities COVID-19 Positive Log documents R100 resided on [NAME] hallway, and developed symptoms of COVID-19 on 7-16-22 of cough, nausea, and not feeling well, and tested positive for COVID-19 on 7-16-22. Residents Affected - Some R100's COVID-19 Antigen Test, dated 7-16-22, documents R100 tested positive for COVID-19. 17. R38's Face Sheet, dated 6-21-22, documents R38 is a [AGE] year-old with diagnoses of Hypothyroidism, Malignant neoplasm of lung, Muscle weakness, Transient cerebral ischemic attack, Type 2 diabetes mellitus, Hyperlipidemia, and Dementia without behavioral disturbance. The facilities COVID-19 Positive Log documents R38 resided on [NAME] hallway, and developed symptoms of COVID-19 on 7-16-22 of sore throat and congestion, and tested positive for COVID-19 on 7-16-22. R38's COVID-19 Antigen Test, dated 7-16-22, documents R38 tested positive for COVID-19. 18. R4's Face Sheet, dated 1-23-20, documents R4 is a [AGE] year-old with diagnoses of Chronic kidney disease, Acute kidney failure, muscle weakness, Hypothyroidism, and Hypertension. The facilities COVID-19 Positive Log documents R4 resided on [NAME] hallway, and developed symptoms of COVID-19 on 7-19-22 of hoarseness and cough, and tested positive for COVID-19 on 7-19-22. R4's COVID-19 Antigen Test, dated 7-19-22, documents R4 tested positive for COVID-19. 19. R85's Face Sheet, dated 7-30-21, documents R85 is an [AGE] year-old, with the diagnoses of Hypokalemia, Diabetes mellitus, Muscle weakness, Cardiac arrhythmia, Hemiplegia, Hypertension, and Hyperlipidemia. The facilities COVID-19 Positive Log documents R85 resided on [NAME] hallway, and developed symptoms of COVID-19 on 7-19-22 of runny nose and fatigue, and tested positive for COVID-19 on 7-19-22. R85's COVID-19 Antigen Test, dated 7-19-22, documents R85 tested positive for COVID-19. 20. R12's Face Sheet, dated 9-07-21, documents R12 is a [AGE] year-old, with the diagnoses of Malignant neoplasm of rectum, Chronic ischemic heart disease, Iron deficiency anemias, Muscle weakness, and Type 2 diabetes Mellitus. The facilities COVID-19 Positive Log documents R12 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 7-26-22 of fever and diarrhea, and tested positive for COVID-19 on 7-26-22. R12's COVID-19 Antigen Test, dated 7-26-22, documents R12 tested positive for COVID-19. 21. R87's Face Sheet, dated 11-21-19, documents R87 is a [AGE] year-old, with the diagnoses of Cerebellar stoke syndrome, Dementia without behavioral disturbance, Muscle weakness, and Hypertension. The facilities COVID-19 Positive Log documents R87 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 8-02-22 of headache and nausea, and tested positive for COVID-19 on 8-02-22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 8 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 R87's COVID-19 Antigen Test, dated 8-02-22, documents R87 tested positive for COVID-19. Level of Harm - Immediate jeopardy to resident health or safety 22. R93's Face Sheet, dated 8-03-22, documents R93 is a [AGE] year-old, with the diagnoses of Iron deficiency anemia, Hyperlipidemia, Parkinson's disease, Anxiety, and Type 2 diabetes. Residents Affected - Some The facilities COVID-19 Positive Log documents R93 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 8-02-22 of sore throat, and tested positive for COVID-19 on 8-03-22. R93's COVID-19 Antigen Test, dated 8-03-22, documents R93 tested positive for COVID-19. 23. R90's Face Sheet, dated 11-27-20, documents R90 is a [AGE] year-old, with the diagnoses of Dementia without behavioral disturbance, Anxiety, Muscle weakness, Hypertension, and Hypothyroidism. The facilities COVID-19 Positive Log documents R90 resided on Eastbrook Lane hallway, and developed symptoms of COVID-19 on 8-15-22 of headache and cough, and tested positive for COVID-19 on 8-15-2022. R90's COVID-19 Antigen Test, dated 8-15-22, documents R90 tested positive for COVID-19. 24. On 8-29-22 at 1:56 PM, R94 was sitting in a contact isolation private room on the Sunny Dale hallway. R94 stated, I still do not feel the greatest. I am still weak. R94's Face Sheet, dated 8-24-22, documents R94 is an [AGE] year-old ,with the diagnoses of Dementia without behavior disturbance, Hypertension, Muscle Weakness, Hyperlipidemia, and Atrial fibrillation. The facilities COVID-19 Positive Log documents R94 resided on [NAME] Gardens hallway, and developed symptoms of COVID-19 on 8-21-2022 of shortness of breath, and tested positive for COVID-19 on 8-22-22. R94's COVID-19 Antigen Test, dated 8-22-22, documents R94 tested positive for COVID-19. V5's (Registered Nurse/RN) Timecard Summary documents V5 worked on the [NAME] Center hallways from 8:24 AM through 4:00 PM on 6-21-22, and 8:32 AM to 4:28 PM on 6-20-22. The facility's COVID-19 Employee Tracking Log documents V5 developed symptoms of COVID-19 on 6-21-22 of a headache, runny nose, cough, and fever, exposed the [NAME] Center residents on 6-20-22 and 6-21-22, and did not test for COVID-19 until 6-22-22. V5's COVID-19 Antigen Testing form, dated 6-22-22, documents V5 tested positive for COVID-19 on 6-22-22 at 7:30 AM. V6's (CNA/Certified Nursing Assistant) Timecard Summary documents V6 worked on the [NAME] Center hallways from 6:08 AM through 2:31 PM on 6-21-22, and 6:06 AM through 10:12 AM on 6-23-22. V6's COVID-19 Self Employee Screening, dated 6-21-22 and 6-23-22 at 6:00 AM, documents V6 had no signs/symptoms of COVID-19. The facility's COVID-19 Employee Tracking Log documents V6 developed symptoms of COVID-19 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 9 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 6-21-22 of a cough, runny nose, and cough, exposed the [NAME] Center residents on 6-20-22, 6-21-22, and 6-23-22, and did not test for COVID-19 until 6-23-22. V6's COVID-19 Antigen Testing form, dated 6-23-22, documents V6 tested positive for COVID-19 on 6-23-22 at 10:00 AM. On 9-1-22 at 9:00 AM, V6 stated, I had a stuffy nose and cough a few days before I tested positive for COVID. I did take a rapid COVID test, and it was negative. I did not know I had to take a PCR test or quarantine while I had symptoms. My supervisors did not tell me that I could not work with symptoms. V7's (LPN/Licensed Practical Nurse) Timecard Summary documents V7 worked on the [NAME] Gardens hallways from 6:24 PM through 9:13 PM on 6-26-22. The facility's COVID-19 Employee Tracking Log documents V7 developed symptoms of COVID-19 on 6-26-22 of fever and body ache, and exposed the [NAME] Center hallway residents on 6-26-22. V7's COVID-19 Antigen Testing form, dated 6-26-22, documents V7 tested positive for COVID-19 on 6-26-22 at 7:30 PM. On 9-1-22 at 11:15 AM, V3 (Assistant Director of Nursing) stated, (V7) did not complete a pre-screening for COVID-19 symptoms before her shift on 6-26-22. V8's (Non-Certified Assistant) Timecard Summary documents V8 worked on the [NAME] Gardens hallways from 6:25 AM through 3:30 PM on 6-26-22, and 6:25 AM through 6:45 AM on 6-27-22. V8's COVID-19 Self Employee Screening, dated 6-25-22, 6-26-22, and 6-27-22 at 6:30 AM, documents V8 had no signs/symptoms of COVID-19. The facility's COVID-19 Employee Tracking Log documents V8 developed symptoms of COVID-19 on 6-24-22 of sneezing and body aches, and exposed the [NAME] Gardens hallway residents on 6-25-22 and 6-26-22. V8's COVID-19 Antigen Testing form, dated 6-27-22, documents V8 tested positive for COVID-19 on 6-27-22 at 6:50 AM. On 9-1-22 at 1:30 PM, V8 stated, I did work with the residents on [NAME] Gardens while I was having body aches and sneezing. I sneezed like 30 times, but did not think anything about it. I thought it was allergies. I was never told to do a PCR test or to quarantine until my symptoms were gone. V9's (CNA) Timecard Summary documents V9 worked on the Eastbrook Lane hallways on 6-24-22 from 6:32 PM until 7:12 AM on 6-25-2022. The facilities COVID-19 Employee Tracking Log documents V9 developed symptoms of COVID-19 on 6-25-22 of sore throat, body aches, and headache, and exposed Eastbrook Lane hallways on 6-24-22. V9's COVID-19 Antigen Testing form, dated 6-28-22, documents V9 tested positive for COVID-19 on 6-28 at 1:52 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 10 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 9-1-22 at 11:15 AM, V3 (Assistant Director of Nursing/ADON) stated, (V9) did not complete a prescreening for COVID-19 symptoms before her shifts on 6-24-22 and 6-25-22. V10's (Housekeeper) Timecard Summary documents V10 worked on the [NAME] Gardens hallways on 6-30-22 from 6:56 AM until 3:30 PM. V10's COVID-19 Self Employee Screening, dated 6-30-2022 at 5:00 AM, documents V10 had no signs/symptoms of COVID-19. The facilities COVID-19 Employee Tracking Log documents V10 developed symptoms of COVID-19 on 6-30-22 of fever and cough, and exposed [NAME] Gardens hallways on 6-30-22. V10's COVID-19 Antigen Testing form, dated 7-01-22, documents V10 tested positive for COVID-19 on 7-01-2022 at 12:26 PM. On 9-1-22 at 1:45 PM ,V10 stated, I had a fever and cough that I got during my shift on 6-30-22. I tried to make it through work, and then I went to the hospital the next morning and was tested for COVID and was positive. V11's (CNA) Timecard Summary documents V11 worked on the [NAME] Gardens hallways on 7-03-22 from 02:03 AM until 11:54 AM. The facilities COVID-19 Employee Tracking Log documents V11 developed symptoms of COVID-19 on 7-03-2022 of runny nose and cough, and exposed [NAME] Gardens hallways on 7-03-2022. V11's COVID-19 Antigen testing form, dated 7-03-2022, documents V11 tested positive for COVID-19 on 7-03-22 at 11:50 AM. On 9-1-22 at 11:15 AM, V3 stated, (V11) did not complete a prescreening for COVID-19 symptoms before her shift on 7-03-22. V12's (CNA) Timecard Summary documents V12 worked on the Eastbrook Lane hallways on 6-29-22 from 6:30 PM until 6-30-22 at 7:15 AM, 6-30-22 from 6:26 PM until 7-01-22 7:00 AM, and 7-01-2022 from 10:30 PM until 7-02-2022 at 6:00 AM. The facilities COVID-19 Employee Tracking Log documents V12 developed symptoms of COVID-19 on 6-28-2022 of cough, sore throat, and double ear infection, and last exposed Eastbrook Lane hallways on 7-02-22. V12's COVID Antigen testing form, dated 7-02-22, documents V12 tested positive for COVID-19 on 7-02-22 at 6:00 AM. On 9-1-22 at 11:15 AM, V3 stated, (V12) did not complete a prescreening for COVID-19 symptoms before her shift on 7-01-22 and 7-02-22. (V12) worked with COVID-19 symptoms on 6-29-22, 6-30-22, 7-01-22, and 7-02-22, exposing all the residents on Eastbrook Lane hallway to COVID-19. On 9-1-22 at 11:52 AM, V12 stated, I had a cough and sore throat for several days before I tested positive for COVID. I worked with the residents while I had symptoms. I did not know I had to quarantine or do a PCR test. I do not remember doing a prescreening for COVID symptoms before my shifts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 11 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some V13's (Non-Certified Assistant) Timecard summary documents V13 worked on the Southern Court hallways on 7-05-22 from 6:32 AM until 3:04 PM, 7-07-22 from 6:32 AM until 2:30 PM, and 7-09-22 from 6:25 AM until 7:17 AM. The facilities COVID-19 Employee Tracking log documents V13 developed symptoms of COVID-19 on 7-07-22 of sore throat, headache, runny nose, and cough, and exposed Southern Court hallways on 7-05-22, 7-06-22, 7-07-22, and 7-09-22. V13's COVID-19 Antigen testing form, dated 7-09-22, documents V13 tested positive for COVID-19 on 7-09-22 at 7:15 AM. On 9-1-22 at 11:15 AM, V3 stated, (V13) did not complete a prescreening for COVID-19 symptoms before her shifts on 7-05-22, 7-07-22, and 7-09-22. On 9-1-22 at 11:50 AM, V13 stated, I did not think anything about my symptoms of a headache, sore throat, or sinus drainage. I never knew I had to report those symptoms to the facility or do a prescreening for COVID before my shifts. I did work with the residents on Southern Court when I had these symptoms. V14's (CNA) Timecard Summary documents V14 worked on the Eastbrook Lane hallways from 5:58 AM through 2:31 PM on 7-9-22, 5:58 AM through 2:35 PM on 7-10-22, and worked the [NAME] hallways from 5:55 AM through 2:30 PM on 7-11-22. The facility's COVID-19 Employee Tracking Log documents V14 developed symptoms of COVID-19 on 7-10-22 of a cough and congestion, and exposed the Eastbrook Lane hallway residents on 7-9-22 and 7-10-22, and [NAME] hallway residents on 7-11-22. V14's COVID-19 Antigen Testing form, dated 7-11-22, documents V14 tested positive for COVID-19 on 7-11-22 at 8:42 AM. On 9-1-22 at 11:15 AM, V3 stated, (V14) did not complete a pre-screening for COVID-19 symptoms before her shifts on 7-9-22, 7-10-22, or 7-11-22. V17's (Dietary Aide) Timecard log documents V17 worked on the Eastbrook Lane hallways on 7-21-22 from 3:49 PM to 8:02 PM, and 7-22-2022 from 3:54 PM to 8:00 PM. V17's COVID-19 Self Employee screening, dated 7-21-22 and 7-22-22 at 4:00 PM, was incomplete and did not include whether V19 had signs/symptoms of COVID-19. The facilities COVID-19 Employee Tracking log documents V17 developed symptoms of COVID-19 on 7-21-22 of sore throat/headache, and exposed Eastbrook Lane hallways on 7-21-22 and 7-22-22. V17's COVID-19 Antigen testing form, dated 7-23-2022, documents V17 tested positive for COVID-19 on 7-23-2022. On 9-1-22 at 4:24 PM, V17 stated, I did not always fill out the prescreening for COVID every day before my shifts. I worked when I had a sore throat, headache, and runny nose. I thought I just had a cold. I did not report my symptoms to anybody. I did end up testing positive for COVID. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 12 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 9-2-22 at 1:00 PM, V3 (Assistant Director of Nursing) provided a list of the following residents who are either unvaccinated or not up to date with their COVID-19 boosters (R4, R7, R20, R26, R38, R45, R51, R63, R64, R72, R83, R88, R90, R91, R93, and R100). On 8-31-22 at 12:30 PM, V3 (Assistant Director of Nursing) stated, I oversee the COVID-19 policy and procedures. The outbreak of the COVID-19 virus with the [NAME] Center residents started with (V5/RN) and (V6/CNA), the outbreak of COVID-19 with the [NAME] Gardens residents started with (V11 CNA), the outbreak of COVID-19 with the Eastbrook Lane residents started with (V17/Dietary Aide), and the outbreak of COVID-19 with the [NAME] residents started with (V14/CNA). (V5, V6, V11, V14, V17) worked with the residents while having symptoms of COVID-19. I do not know why (V5, V6, V11, V14, V17) did not report that they were having symptoms. All employees are to screen themselves for COVID-19 before the start of their shifts every day. Not all staff have been screening themselves prior to their shifts. I do not think anybody is monitoring to make sure staff are prescreening for symptoms before their shifts. The staff have been in-serviced that they are to report to their supervisor immediately if they have signs and symptoms of COVID-19, and not work with the residents. Employees who have symptoms of COVID-19 are supposed to rapid test immediately for COVID-19. If the employee is negative by rapid testing, the employee must submit a PCR (Polymerase Chain Reaction) test for COVID-19 and quarantine until they receive the result of the PCR. I did not know that residents who are unvaccinated or not up to date with the COVID-19 vaccination are to be isolated once coming into contact with anyone symptomatic or testing positive of COVID-19. (R4, R7, R20, R26, R38, R45, Event ID: Facility ID: 145773 If continuation sheet Page 13 of 14 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 145773 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Samaritan Home 2130 Harrison Street Quincy, IL 62301 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review and interview, the facility failed to offer and administer all required boosters for the Pfizer-BioNTech and Moderna COVID-19 (Coronavirus Disease 2019) vaccinations to maintain these residents up to date for 24 of 26 residents (R3, R7, R11, R20, R26, R35, R41, R45, R50, R51, R63, R64, R75, R78, R79, R80, R81, R88, R89, R90, R91, R93, R96, R104) reviewed for COVID-19 immunizations in the sample of 60. Findings include: The facility's COVID-19 Infection Prevention and Control Program policy, dated March 22, 2022, documents, Description: (The facility) has developed a COVID-19 infection prevention and control program to decrease the risk of residents and staff becoming infected with SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), the virus that causes COVID-19. Vaccinations and Vaccine Boosters: COVID-19 vaccinations and vaccine boosters will be offered to all consenting and eligible employees and residents onsite at scheduled dates and times through the (local health department). Additional vaccination locations will be used as they become available. The CDC (Centers for Disease Control and Prevention) COVID-19 webpage, dated 5-24-22, documents: Vaccines: Primary Series: Doses of Pfizer-BioNTech given three to eight weeks apart. Fully Vaccinated: Two weeks after final dose in primary series. Boosters: One booster for most people at least five months after the final dose in the primary series. Second booster of either Pfizer-BioNTech or Moderna COVID-19 vaccine for adults ages 50 years and older at least four months after the first booster. Up to Date: Immediately after getting all boosters recommended for you. On 9-2-22 at 1:00 PM, V3 (Assistant Director of Nursing), provided a list of the following residents (R3, R7, R11, R20, R26, R35, R41, R45, R50, R51, R63, R64, R75, R78, R79, R80, R81, R88, R89, R90, R91, R93, R96, R104) who have been due for the Pfizer booster or Moderna booster. These same residents or POAs (Power of Attorney) have given consent to receive the booster; However, the facility has not provided the booster to these identified residents. On 8-31-22 at 12:30 PM, V3 (Assistant Director of Nursing) stated, Most of the resident's boosters were due in February 2022, and the resident's did not get them. The health department did not come to the facility to offer boosters until June, 2022, when there was an outbreak of COVID-19 within the facility. We (the facility) did not try to get the residents boosted by taking them anywhere else, and did not contact the health department before June to see if they could get the (eligible) residents their boosters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 14 of 14