Inspection·April 4, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's X-ray report, dated 3/22/23, states R1's X-ray is a somewhat hampered study but shows a possible subcapital left humeral head fracture with the recommendation to correlate with a CT (computed tomography). On 4/4/23 at 10:10a.m. V12 (Nurse Practitioner) stated V12 is not certain R1 has a humerus fracture. V12 stated R1 never expressed any pain, including when V12 moved R1's left arm to check for R1's range of motion, and R1 did not have any bruising or swelling. V12 stated R1's range of motion to her left arm is unchanged since before R1's X-ray. V12 stated because R1 was unable to hold still for the study, the X-ray is not conclusive. V12 stated R1's family chose not to have a CT scan to confirm the information in the X-ray. R1's care plan does not include a documented intervention on how to safely transfer R1 until 3/23/23, when the intervention of (R1) to be transferred via (Full mechanical) Lift from this point forward to ensure safety to resident and to staff was added. On 4/3/23 at 12:42p.m. V4 (CNA) stated a (safety) belt is supposed to be applied prior to transferring residents from place to place. V4 demonstrated how the (safety) belt is applied around a resident's waist. V4 stated once the (safety) belt was in place, the CNAs will grab the (safety) belt on the back side of the resident and pull on it to assist the resident to stand. V4 stated no pressure is applied under the resident's arm pit area during the (safety) belt transfer. V4 stated a safety belt is not used during a mechanical lift transfer because the resident is secured in place with a mechanical lift sling. At 1:00p.m., R1 was seated in a wheelchair in her room next to the bed. R1's neck and head were tilted towards R1's right shoulder. R1's left upper arm was against R1's side with both R1's arms stretched out and crossed at the wrist. R1 was able to move both her arms, but the movement appeared to be involuntary. V4 and V5 (CNAs) entered R1's room with a mechanical lift machine and proceeded to attach R1's lift sling, which was situated under R1, then used the lift to transfer R1 to bed. V4 and V5 then applied wedges in front of and behind R1 to help R1 maintain a side-lying position. On 4/3/23 at 2:12p.m. V9 (CNA) stated on 3/22/23 at approximately 3:15p.m., she and another CNA were preparing to transfer R1 from the bed to the wheelchair using the full mechanical lift. V9 stated R1's left arm looked different than usual. V9 stated R1's arm was completely straight, which is unusual, and it was also rotated inward. V9 stated she told R1's nurse, who evaluated R1's arm, then called R1's practitioner for orders. V9 stated R1 had an X-ray to her left arm later that evening. V9 stated she and another CNA did transfer R1 from the bed to the wheelchair during her shift, but R1 did not show any signs of discomfort or pain. On 4/3/23 at 3:16p.m., V10 (CNA) stated on 3/22/23 in the early morning before 6:00a.m., he and V11 (CNA) transferred R1 from the bed to the chair by standing and pivoting R1. V10 stated he and V11 did not use a gait belt to transfer R1. V10 stated when he and V11 transferred R1, they put their arms under R1's armpit area then pulled R1 up into a standing position before placing R1 into the wheelchair. V10 stated he and V11 should have applied a (safety) belt around R1's waist before standing R1. On 4/3/23 at 3:24p.m., V11 verified on 3/22/23 in the early morning, he and V10 placed their arms under R1's armpit area then lifted R1 up into a standing position before placing R1 into the wheelchair. V11 also verified neither V10 nor V11 placed a safety belt around R1's waist before the transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 2 of 3 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 04/04/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 4/3/23 at 9:15a.m., 12:40p.m., and on 4/4/23 at 9:15a.m. and 12:40p.m., V2 (Director of Nurses) stated she investigated R1's potential fractured left arm. V2 stated her investigation could not determine a cause of R1's potential left arm fracture. V2 stated V9 and V10 were both provided with the facility's Safe Handling policy at the time of hire, and both V9 and V10 signed they received and understood this policy. V2 stated R1 should not have been transferred without a gait belt placed around R1 for safety. V2 stated she was not aware R1 had been assessed as requiring full mechanical lift transfers as of 2/3/23. V2 stated although R1 had been on a restorative stand-pivot transfer program in the past, she could provide no documentation R1 was still on a restorative stand-pivot transfer program after 2/2023. V2 verified R1's care plan did not include interventions for how R1 should be transferred until 3/23/23. Event ID: Facility ID: 145773 If continuation sheet Page 3 of 3