Health inspection·October 27, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Based on record review and interview, the facility failed to provide documentation by a physician regarding the basis of a resident's involuntary discharge with indications for why a resident should not return to the facility following hospitalization, what resident needs could not be met at the facility, what the facility's efforts were to meet those needs, and the specific services the receiving facility could provide to meet the needs of the resident which could not be met at the facility for one of three residents (R1) reviewed for involuntary discharge in the sample of four. Findings include: R1's Progress Notes, dated 8-31-24 at 4:00 PM, document R1 was sent to the emergency room by ambulance due to R1 having combative behaviors, threatening staff and (V10/R1's Family Member), hallucinating, and having increased paranoia. R1's Progress Notes, dated 9-1-24 at 2:16 AM, document R1 was being admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. R1's Progress Notes, dated 9-12-24 at 3:00 PM and signed by V4/Admission's Coordinator, document, Admissions: Spoke with (V1/Administrator) and (V2/Director of Nursing) about (R1's) possible return to (the facility). They (V1 and V2) feel that (R1's) condition has changed to a point that our staff can no longer meet (R1's) needs. Notified (V8/Hospital Case Manager) and (V10) that (R1) cannot return to (the facility) due to his condition changing to a point that our staff can no longer meet (R1's) needs. (R1) will be discharged from (the facility) to the hospital effective today 9-12-24. R1's Medical Record and Physician's Orders, dated 8-31-24 to 10-26-24, do not include documentation by V17/R1's Physician regarding the basis of R1's involuntary discharge with the indications for why R1 should not return to the facility following hospitalization, what needs of R1 could not be met at the facility, what the facility's efforts were to meet R1's needs, and the specific services the receiving facility could provide to meet R1's needs of which could not be met at the facility. On 10-25-24 at 11:05 AM, V9 (Nurse Practitioner) stated, I cover for (V17/R1's Primary Physician). I was not consulted by the facility when the facility decided not to let (R1) come back. I know (V17) was not consulted, either therefore there was no documentation by (V17) or myself of why the facility could not meet (R1's) needs. I did not know the decision was being made to not re-admit (R1) back to the facility. On 10-25-24 at 1:30 PM, V1 (Administrator) verified the facility does not have an involuntary discharge policy and did not receive an order or get documentation by V17/R1's Physician regarding the (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 10/27/2024 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)