Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident was provided timely provider notifications
to ensure medical intervention was received with an acute change in condition for one of four residents (R1)
reviewed for change in condition in the sample of four. This failure resulted in R1 experiencing a delay in
evaluation and treatment while experiencing an acute ischemic stroke.Findings include:The facility's
Change in Resident Condition Policy, dated 10/8/24, documents, Standard: The attending physician,
resident representative, and RCC (Resident Care Coordinator) will be notified of any change in the
condition of a resident. Policy: A significant change in a resident's condition must be relayed to the
physician, resident, representative, RCC, and DON (Director of Nursing) or ADON (Assistant Director of
Nursing) timely. Procedure: 2. Any significant change in a resident's condition must be immediately relayed
by phone to the attending physician and the resident representative. In addition, notify the supervisor, RCC,
DON, or ADON. A significant change in condition is a major decline in a resident's status that will not
normally resolve itself without interventions. A significant change in condition may include but not be limited
to the following: B. Emergent Situations: Symptoms such as chest pain, loss of consciousness, or other
signs or symptoms of heart attack or stroke that may signify a significant change. Sudden unexpected
decline in a resident's condition. 4. Call the physician or provider on-call for questions, concerns, or any
significant change in condition.R1's Face Sheet documents R1 is an [AGE] year-old female who admitted to
the facility on [DATE] with the following, but not limited to, diagnoses: Postprocedural hemorrhage of right
eye and adnexa following other procedure, Repeated Falls, Tinea Pedis, and Encephalopathy.R1's MDS
(Minimum Data Set) Assessment, dated 7/1/25, documents R1 is cognitively intact and requires
supervision or touching assistance with ambulation, sitting to standing, and transfers. This same MDS
documents R1 has no impairments to R1's upper or lower extremities.R1's Care Plan, dated 7/8/25,
documents, Problem Start Date: 07/08/2025 ADLs (Activities of Daily Livings) Functional
Status/Rehabilitation Potential: (R1) requires varying levels of assist d/t (due to) Weakness, Ataxia and
Edema. Approach Start Date: 07/08/2025 Report any further deterioration in status to physician.R1's
Progress Note, dated 9/11/25 and signed by V9/Agency LPN (Licensed Practical Nurse), documents, (R1)
was complaining of left leg weakness and vision problems. (R1) was seen yesterday by (V4/R1's Nurse
Practitioner) for these issues. (R1) weakness increased with left leg, needing assistance to transfer to the
bathroom. Vital Signs in normal range, ask (R1) if she was in pain, dizzy, or having headache, (R1) voiced
no, but her vision was not good and left leg weak. (R1) ate well both meals talking well, took (R1) to the
bathroom and to chair to elevate legs, (R1) took a nap. Checked on (R1) her head was down to neck and
looked uncomfortable in chair, (R1) woke up and complaints of pain in neck. (R1) asked to go the bathroom
(R1's) left arm was flaccid, (R1) transferred two assists. (R1) request to be seen. This same progress
documents V10/Nurse Practitioner was notified and
(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 3
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
09/19/2025
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 0580
Level of Harm - Actual harm
Residents Affected - Few
gave an order to send R1 to local emergency room.R1's local ED (Emergency Department) Note, dated
9/11/25, documents, Chief Complaint: Stroke-Like Symptoms. (R1) is an [AGE] year-old who presents to
the ED with complaints of stroke-like symptoms that began today. (R1) reports waking up with vision
problems and requiring assistance to go to the bathroom. This same ED Note documents, Critical Findings:
Acute Ischemic Stroke. Admit to Hospital.R1's Hospital Discharge Orders and Summary, dated 9/14/25,
documents, Admitting Diagnoses: Left-Sided Weakness and Stroke.On 9/18/25 at 11:46 AM, R1 stated a
day or two before being admitted to the hospital on [DATE], R1 experienced changes in vision and reported
having leg cramps. A Nurse Practitioner, identified as V4, reportedly saw R1 the day before R1's hospital
admission and initiated new orders. The day of R1's hospital admission, before lunch, R1 reported her
vision changes became more severe, and developed weakness to her left leg. R1 used her call light
because she was too weak to transfer on her own and had to use the bathroom. R1 stated, Two staff
members had to assist me to the bathroom. I could not move my left leg and I reported my vision was
getting worse. R1 reported a nurse, identified as V9/Agency LPN, came down and assessed R1 and told
R1, V4/Nurse Practitioner, had previously assessed R1 the day prior, so V9 was just going to monitor R1.
R1 stated, I went to lunch and my vision was getting worse and my left leg was extremely weak. Again, (V9)
told me (V4) had just seen me the day prior, so she pushed me down to my room, assisted me to my
recliner, and elevated my legs. (V9) told me to try and rest. Around two to three hours later, I put back on
my call light to get help with using the bathroom. At this time, I was unable to move my left leg, my left arm,
and could hardly see. It took two staff members to assist me to the bathroom once again. (V9) finally sent
me out to the ED.On 9/18/25 at 1:27 PM, V11/CNA (Certified Nursing Assistant) stated she was working
with R1 on 9/11/25, the day R1 was sent out to the local hospital. V11 stated, (R1) did not complain of
anything early that morning. Right before lunch (R1) had turned on her call light. (V12) and I went to (R1's)
room and (R1) was visibly upset saying she needed to use the bathroom. (R1) expressed to me that
something was wrong with her vision and her left leg. (R1) was complaining of weakness on her left side
and could not physically lift her left leg. (V12) and I assisted (R1) to the bathroom. As we stood (R1) up to
hold on to the grab bars in the bathroom, (V12) and I had to manipulate (R1's) left leg to get her positioned
correctly to sit on the toilet. (R1) was unable to move her left leg which was out of character for (R1). V11
expressed R1 never utilizes her call light or asks for assistance. V11 reported she notified V9/Agency LPN
to let her know about the new concerns with R1, V9 came to examine R1 and stated since V4 had already
seen her the day prior, V9 would just monitor R1. V11 stated, I did express to (V9) that something was not
right with (R1) and that (R1) never requires assistance.On 9/18/25 at 1:35 PM, V9/Agency LPN verified she
was the nurse taking care of R1 on 9/11/25, the day R1 was sent to the local hospital. V9 stated, Before
lunch I was called to (R1's) room. (R1) was complaining of her left leg being weak and having some vision
trouble. (R1) required more assistance at that time to go to the bathroom. I had read (R1's) notes and (V4)
had been in to see her the day prior for leg cramps and vision changes. I let (R1) know that and told (R1) I
would monitor her. I did not call a physician at that time. (R1) ate lunch fine but was still complaining of
some vision changes and left leg weakness. I let (R1) know that (V4) had written an order for (R1) to see an
ophthalmologist again, and that I would push (R1) to her room and assist her withing propping her leg up in
the recliner and told (R1) to try and rest. When (R1) woke up around 3:00 PM, (R1) was complaining of
neck pain. (R1) was talking fine and responding fine but stated her left leg didn't feel right. I called
(V12/CNA) to assist me with taking (R1) to the bathroom. At that time (R1's) mobility decreased even more.
I then called (V10/Nurse Practitioner) at that time and got (R1) sent out to the local hospital. V9 reported
(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
09/19/2025
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 0580
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
when V9 typed R1's assessments in R1's progress note, V9 did not document correct times of when R1
was complaining of everything. V9 verified she typed everything that occurred throughout the day in one
progress note right before she sent R1 out to the local hospital. V9 confirmed she should have documented
R1's events throughout the day as they occurred at the correct times.On 9/19/25 at 10:43 AM V12/CNA
stated, I was getting resident's up for lunch, when (R1) had put on her call light sometime between 11:00
AM and 11:30 AM. It was weird that (R1) had her call light on because (R1) is independent and never uses
her call light. (V11/CNA) and I both went down to (R1's) room. (R1) was saying her eyes were bothering
her, (R1) couldn't see how she normally could, and that (R1) couldn't really move her left leg. (R1) stated
she was needing to go to the bathroom. (V11) and I assisted (R1) to the bathroom. When (V11) and I
assisted (R1) up to the grab bar in the bathroom, (R1) could hardly move her left leg and (V11) and I had to
help guide it, to get (R1) on the toilet. (V11) went and got (V9/Agency LPN) because something was not
right with (R1). (R1) never requires assistance. (V9) came to (R1's) room, but basically just told (R1) that
(V4/R1's Nurse Practitioner) was already aware from the day prior and that (V9) would just monitor (R1). I
am not sure how (R1) got back to her room after lunch because I was called to work on a different unit for a
few hours. When I got back to the floor (V9) had asked me if I could come to (R1's) room and help (V9)
assist (R1) to the bathroom. This was around 3:00 PM. When I got to (R1's) room (R1) stated she now was
unable to move her left arm. I believe right after that is when (V9) got (R1) sent out to the hospital.On
9/18/25 at 12:39 PM, V4/R1's Nurse Practitioner stated she saw R1 on 9/10/25 at the facility. R1 told V4 she
was having cramps in her legs, and it was worse at night along with vision changes. V4 stated she did
initiate orders for V4, but at that time didn't see any stroke-like symptoms. V4 stated, (R1) could move her
left leg up and down when I had seen her and had no problems with weakness. I did initiate orders for
(R1's) complaints of leg cramps. I would have expected the facility to notify (V17/R1's Physician) or myself
right away if (R1's) if (R1) was experiencing increased weakness or required more assistance with ADL's
(Activities of Daily Living).On 9/19/25 at 10:02 AM, V2/Director of Nursing verified she would have expected
a nurse to notify the resident's provider immediately with any significant changes in a resident's condition
like R1 was experiencing on 9/11/25 when R1 first was requiring more assistance with ADL's and
complaining of increased weakness and more severe vision changes.
Event ID:
Facility ID:
145773
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the September 19, 2025 survey of GOOD SAMARITAN HOME?
This was a inspection survey of GOOD SAMARITAN HOME on September 19, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GOOD SAMARITAN HOME on September 19, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.