Health inspection·August 19, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to respond immediately to a sounding exit door alarm, failed to adequately supervise a known wandering resident (R8), failed to re-assess R8 as high risk for elopement once R8 started to exit seek, failed to develop and implement interventions and plan of care to address R8's exit-seeking behaviors after R8 attempted to exit seek, and failed investigate and report R8's elopement thoroughly for one of three residents (R8) reviewed for elopement in the sample of 41. These failures resulted in R8, a severely cognitively impaired resident with the diagnosis of Dementia, eloping from the facility approximately 70 feet from the facility, falling, and being found on the curb next to the road, after attempting to exit the building earlier that evening on 6-7-23. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-19-23, the facility remains out of compliance at a severity Level II as the facility continues to investigate R8's elopement on June 7, 2023, and provide a final report to IDPH within five days, provide in-servicing to all staff on R8's elopement interventions and the facility's Elopement Policy, including the Administrator/V11 upon her return to the facility on 8-21-23, residents are assessed quarterly and with a change in condition or when exhibiting exit seeking behavior for elopement risk, and each exit-seeking episode by residents will be audited by V13 (Compliance Officer) and re-education will be provided and disciplinary action for noncompliance will be given as necessary. Findings of all audits and re-education will be reported to the QAA (Quality Assurance Assessment) committee and the compliance committee on a quarterly basis and reviewed monthly by the QAPI (Quality Assurance and Performance Improvement) committee. Findings include: The facility's Resident Elopement Policy, dated 6-12-18, documents, Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. All staff are responsible. Missing resident shall be defined as a resident who has left the main building without signing him/herself out of the facility. Residents who are at risk for elopement shall be provided at least one of the following safety precautions by the facility: Door alarms on facility exits, code alert bracelet, staff supervision of facility exits, and pictures of residents at risk for elopement will be kept at the front desk for quick identification. Elopement assessment will be done on admission, quarterly, and change in condition which puts them at risk for elopement. Residents at risk for impaired safety awareness and wandering as well as elopement shall be identified by the elopement assessment and interventions documented in the individual plan of care. Residents at (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 5 Event ID: 145773 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 08/19/2023 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)