Inspection·August 15, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm R35's Event Report, dated 7-21-24 at 1:58 PM and signed by V7 (LPN/Licensed Practical Nurse/LPN), documents, Dark purple bruise to right hip 10 cm round. Was event witnessed? No. R35's Medical Record does not include R35's bruises of unknown origin found on 4-8-24 or 7-21-24 being reported to IDPH (Illinois Department of Public Health) Residents Affected - Few On 08/13/24 at 1:30 PM V2 (Director of Nursing/DON) stated, Both of (R35's) bruises were unwitnessed. I did not report (R35's) bruises of unknown origin to the state (IDPH). 2. R81's current electronic Medical Record documents R81 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Parkinson's Disease with Dyskinesia, Dementia, Malignant Neoplasm of Uterine Adnexa, Depression, Polyneuropathy, and Anxiety. R81's MDS Assessment, dated 6/10/24, documents R81 has a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. R81's Nursing Note written by V9/Licensed Practical Nurse/LPN, dated 7/18/24 at 9:46 AM, documents, CNA (Certified Nursing Assistant) came to this nurse and said (R81) has a dark purple bruise on back of right leg, bruising with redness on rt (right) upper leg, and several discoloration areas on both of (R81's) arms. R81's Event Report, dated 7/18/24 at 9:54 AM and signed by V9 (LPN/Licensed Practical Nurse/LPN), documents, Right leg bruise is three cm/centimeters by two cm, upper right leg five cm by three cm, and several two cm discolorations to both arms. The bruises are purplish black and reddish blue in color with mild pain. Was event witnessed? No. Residents Statement Doesn't know how it happened. On 8/14/24 at 1:15 PM, V2, Director of Nursing/DON stated she does not know how R81 got the bruises to her legs and arms, but assumes it was from when a family member helped R81 to the bathroom. V2 also stated there was no notification sent to the State Agency to report the bruises on R81. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 2 of 7 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 08/15/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to initiate abuse investigations for bruises of unknown origin for two of two residents (R35 and R81) reviewed for abuse in the sample of 34. Residents Affected - Few Findings include: Abuse Prevention Program Facility Policy, dated 6/19/2021, documents, Internal Reporting Requirements and identification of Allegations, The nursing staff is responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response. 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation. 3. For any other incident or pattern involving reasonable cause to suspect abuse, neglect or misappropriation, the administrator will appoint a person to gather further facts prior to making a determination to conduct an abuse investigation. An injury should be classified as an injury of unknown source when both the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example), the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injury overtime. 1. R35's MDS (Minimum Data Set) Assessment, dated 6-7-24, documents R35 is severely cognitively impaired. R35's Progress Notes, dated 7-21-24 at 1:59 PM, documents, While taking (R35) to the bathroom noted a ten cm (centimeter) round dark purple bruise to rt (right) hip. possibly from bumping on shower chair or bars on toilet. R35's Progress Notes, dated 4-8-24 at 5:36 AM, documents, (R35) was provided (a) shower this am and a bruise on left inner thigh (was found) measuring nine inches by eight inches was noted. Area is dark blue/black in color. (R35) states that it does not hurt. R35's Event Report, dated 4-8-24 and signed by V8 (LPN/Licensed Practical Nurse), documents, Bruise to left inner thigh. Was event witnessed? No. Color black, blue. Size nine cm (centimeters) by eight inches. R35's Event Report, dated 7-21-24 at 1:58 PM and signed by V7 (LPN/Licensed Practical Nurse/LPN), documents, Dark purple bruise to right hip 10 cm (centimeters) round. Was event witnessed? No. R35's Medical Record does not include an abuse investigation of R35's bruises of unknown origin found on 4-8-24 or 7-21-24. On 08/13/24 at 1:30 PM, V2 (Director of Nursing/DON) stated, I did not do abuse investigations of (R35's) bruises of unknown origin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 3 of 7 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 08/15/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R81's current electronic Medical Record documents R81 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Parkinson's Disease with Dyskinesia, Dementia, Malignant Neoplasm of Uterine Adnexa, Depression, Polyneuropathy, and Anxiety. R81's MDS Assessment, dated 6/10/24, documents R81 has a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. R81's Nursing Note written by V9/Licensed Practical Nurse/LPN, dated 7/18/24 at 9:46 AM, documents, CNA (Certified Nursing Assistant) came to this nurse and said (R81) has a dark purple bruise on back of right leg, bruising with redness on rt (right) upper leg, and several discoloration areas on both of (R81's) arms. R81's Event Report, dated 7/18/24 at 9:54 AM and signed by V9 (LPN/Licensed Practical Nurse/LPN), documents, Right leg bruise is three cm/centimeters by two cm, upper right leg five cm by three cm, and several two cm discolorations to both arms. The bruises are purplish black and reddish blue in color with mild pain. Was event witnessed? No. Residents Statement 'Doesn't know how it happened.' R81's Medical Record does not include an abuse investigation of R81's bruises of unknown origin found on 7/18/24. On 8/14/24 at 1:15 PM, V2, Director of Nursing/DON stated she did not do an abuse investigation regarding R81's bruise found on 07/18/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 4 of 7 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 08/15/2024 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure a resident was transferred safely during a shower to avoid falling for one of five residents (R45) reviewed for falls in the sample of 34. Residents Affected - Few Findings include: The facility's Program for Reduction of Fall Risk, dated 7/23/15, documents, As part of the program for the prevention of falls, all newly admitted residents and those residents experiencing a change in function will be assessed for the risk of falls. Interventions to prevent falls will be implemented on the basis of the risk assessment. Purpose: To prevent falls and enable staff to recognize those residents who have been found to be at increased risk for falls. R45's current Care Plan, dated 5/28/24, documents, I (R45) have had a decline in my strength/independence during transfers. I use a (mechanical lift) lift for transfers. This same Care Plan documents, I am at increased risk for falls related to impaired cognition, poor safety awareness, diuretic use and weakness. I use a mechanical lift. R45's Safety Event Fall report, dated 7/19/24, documents R45 suffered a fall in the shower room at 5:40 AM while being transferred by V10 (Certified Nursing Assistant). This form documents, Summary of Findings: (R45's) Knees buckled, (mechanical lift) was not in use. Interventions in place to prevent future falls: Staff re-educated to review assignment sheet and obtain report requiring transfer needs. On 8/14/24 at 2:18 PM, V3 (Assistant Director of Nursing) confirmed R45 fell in the shower room with V10 on 7/19/24. V3 stated, The nurse who was on that morning (V11, Licensed Practical Nurse) went into the shower room and found (R45) on the floor on his knees and (V10) standing in front of him. He had been having a decline and became a (mechanical lift) for all transfers on 7/11/24. (V10) had wheeled (R45) into the shower room on 7/19/24 and then assisted him to transfer to standing, using a gait belt. (R45's) knees buckled and that is when he fell. The intervention for this was to educate staff on ensuring they are aware of all transfer status when oncoming to their shift. She (V10) just didn't use the proper equipment to transfer (R45). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 5 of 7 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 08/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to use the Heat Stickers to ensure dishes reach the correct/required surface temperature when in the rinse cycle in the dish machine and failed to have staff wash hands with soap and water as required between handling dirty dishes and clean dishes in the dish room. This has the potential to affect all 101 residents living in the facility. Findings: 1. The document, Dish Machine Temperature Recording for Food Service Staff Policy, 4/2024, states, It is the policy of the Food Service Department that the acceptable wash temperature (should be) 150 - 165 degrees Fahrenheit (F) and the acceptable rinse temperature is 180 degrees F or above. Any temperature reading below 150 degrees F wash, or 180 degrees F rinse should be noted, and a department supervisor or designee notified. On 8/12/24 at 10:55 AM, V5, Assistant Dietary Manager, stated, We do not use the Surface Temperature Stickers for the dish machine. You (Illinois Department of Public Health (IDPH) Surveyor) had me get the (surface temperature stickers) last time, and I ended up throwing them away because they became outdated. Writer inquired if the surface temperature stickers were being used as required after the IDPH surveyor was last at the facility. V5 did not respond to the question stating, I've been told that we do not need to use the surface temperature stickers. I put a thermometer in the rack and send it through the dish machine. If it registers 160 degrees F, then it's okay. V15, Dietary Manager, has a calculation that shows the temperatures reach what they should. Writer explained without using the surface temperature stickers, it would be unknown if they reached the appropriate surface level of heat for dishes, utensils, glasses, etc . V5 stated, No one else requires the surface temperature stickers to be used. Why do you? I will get (V15) to explain that we don't need the surface temperature stickers. When V15 was asked about this issue, V15 stated, Yes the surface temperature stickers should be used, and I will order them right away. 2. The document, Handwashing, dated 2/2024, states, Proper handwashing technique is used for the prevention of transmission of infectious diseases. A policy for when it is required to wash hands when in the kitchen was requested. The facility states that they do not have a specific policy of when to wash hands, including when staff are using the dish machine. On 8/12/24 at 11:05 AM, V6, Dietary Aide, was observed putting dirty dishes and equipment into racks and sending the soiled dishes through the dishwasher. V6 then reached up, got a squirt out of the sanitation solution container that is affixed to the wall next to the dishwasher and above the area where the dirty dishes are racked. V6 rubbed his hands together and then proceeded to take clean dishes and other clean equipment out of the just washed items in the racks and put them on a cart to be taken into the kitchen. V6 stated. Yes, I always use the sanitation solution. On 8/12/24 at 11:10 AM, V5, Assistant Dietary Manager, stated, I noticed that they didn't have a handwashing sink in the dish room, but use the sanitizer solution when I started working here. I was told that a hand washing sink would not be put in the dish room. Staff should go into the kitchen and wash their hands between handling the dirty dishes and clean dishes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 6 of 7 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 08/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671, dated 8/12/24, signed by V2, Director of Nursing, documents 101 residents currently reside within the facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145773 If continuation sheet Page 7 of 7