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 Page 1 of 5 145773 145773 10/27/2024 Good Samaritan Home 2130 Harrison Street Quincy, IL 62301

F 0622 Level of Harm - Minimal harm or potential for actual harm 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. V1 stated, I did not know we (the facility) need to have documentation by the physician in (R1's) record with the reason for (R1's) discharge with the needs the facility could not meet. Residents Affected - Few 145773 Page 2 of 5 145773 10/27/2024 Good Samaritan Home 2130 Harrison Street Quincy, IL 62301

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review and interview, the facility failed to notify the resident, resident's representative, and the Ombudsman in writing of the reasons for discharge for one of three residents (R1) reviewed for involuntary discharge notice in the sample of four. Findings include: The Ombudsman's Residents' 'Rights for People in Long-Term Care Facilities policy, dated 11/2018, documents, You have the right to keep living in your facility. You must be given written notice if your facility wants you to move from the facility. The notice must: tell you why your facility wants you to move; tell you how to appeal the decision to the Illinois Department of Public Health; and provide a stamped and addressed envelope for you to mail your appeal in. 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 (R1's) 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, dated 8-31-24 to 10-26-24, does not include documentation of R1, V10/R1's Family Member, or V16/Ombudsman being given a notice of discharge regarding the basis of R1's involuntary discharge with the indications of 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 11:28 AM, V10 (R1's Family Member) stated, I was not provided a written notice of (R1's) discharge from the facility. On 10-25-24 at 1:30 PM, V1 (Administrator) verified the facility did not provide R1, V10/R1's Family Member, or V16/Ombudsman a notice of discharge 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 4:00 PM, V16/Ombudsman, stated, The facility never notified me that they were refusing to re-admit (R1) back to the facility from the hospital. I should have received a written notice. It is important that I get a notice so I can meet with the resident and the resident's family to 145773 Page 3 of 5 145773 10/27/2024 Good Samaritan Home 2130 Harrison Street Quincy, IL 62301

F 0623 ensure they know their appeal rights and I can help to ensure (R1) gets proper placement at another facility to meet his needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145773 Page 4 of 5 145773 10/27/2024 Good Samaritan Home 2130 Harrison Street Quincy, IL 62301

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record review and interview, the facility failed to provide a bed hold notice to a resident and a resident's representative upon transfer to the hospital for one of three residents (R1) reviewed for bed hold notice in the sample of four. Findings include: The facility's Bed Hold and readmission Policy, dated 10-26-18, documents, Purpose: The primary purpose of the policy for bed hold and readmission to (the facility) is to establish uniform guidelines for the resident, family member, or legal representative in the event a resident is transferred to a hospital, to another level of care, or takes a leave of absence from the home. A written copy of the bed-hold policy will be provided to the resident at the time of transfer for hospitalization or therapeutic leave. R1's Progress Notes, dated 8-31-24, document R1 was sent to the emergency room and admitted to the hospital. R1's Medical Record does not include documentation of a bed hold noticed being given to R1 nor (V10/R1's Family Member) after R1 was sent to the hospital on 8-31-24. On 10-25-24 at 11:28 AM, V10 (R1's Family Member) stated, Me and (R1) were not given a bed hold notice when (R1) was sent to the hospital on 8-31-24. I do not even know what that notice is about. On 10-26-24 at 10:15 AM, V2 (Director of Nursing) stated, We (the facility) did not send a bed hold notice to (V10) and there is no documentation in (R1's) medical record of the facility giving (R1) a bed hold notice. 145773 Page 5 of 5