Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Home during CMS and state inspections, most recent first.
A resident with a history of falls and encephalopathy experienced new left-sided weakness and vision changes, requiring increased assistance with ADLs. Despite these significant changes, the LPN on duty did not immediately notify the provider, choosing instead to monitor the resident because a nurse practitioner had seen her the previous day. The provider was only contacted after the resident's condition further deteriorated, resulting in delayed evaluation and treatment for an acute ischemic stroke.
Two residents with wounds did not receive wound care under Enhanced Barrier Precautions (EBP) as required by facility policy. A nurse performed wound care using only gloves, omitting the use of a gown, and justified this by stating the wounds did not have drainage that soaked through dressings and there was no MDRO diagnosis. The DON confirmed EBP should be used for all residents with wounds, regardless of drainage.
A facility failed to document the involuntary discharge of a resident following hospitalization. The resident was initially sent to the ER due to behavioral issues and admitted for a UTI and chronic kidney disease. The facility did not consult the resident's physician or nurse practitioner, resulting in a lack of documentation on why the resident could not return, unmet needs, and efforts made. The administrator confirmed the absence of a discharge policy and necessary documentation.
A facility failed to provide a resident, their family, and the Ombudsman with a written discharge notice, as required by policy. The resident was hospitalized for a urinary tract infection and chronic kidney disease, and the facility decided not to readmit them due to their condition. However, no written notice detailing the reasons for discharge or appeal rights was provided, as confirmed by interviews with the family member, administrator, and Ombudsman.
A facility failed to provide a bed hold notice to a resident and their family member upon the resident's transfer to the hospital, as required by the facility's policy. The resident's family member confirmed they did not receive the notice, and the DON acknowledged the oversight and lack of documentation in the resident's medical record.
The facility failed to use Heat Stickers to ensure proper dishwashing temperatures and lacked a specific handwashing policy for kitchen staff. A Dietary Aide used a sanitation solution instead of washing hands with soap and water between handling dirty and clean dishes. The absence of a handwashing sink in the dish room was noted, and staff were instructed to wash hands in the kitchen, which was not being followed.
The facility failed to report bruises of unknown origin for two residents to the State Agency, violating their Abuse Prevention Program Policy. One resident, severely cognitively impaired, had unwitnessed bruises on the hip and thigh, while another resident with moderate cognitive impairment had multiple bruises on the legs and arms. The Director of Nursing did not report these incidents to the Illinois Department of Public Health.
The facility did not conduct required abuse investigations for two residents with bruises of unknown origin. One resident, with severe cognitive impairment, had multiple bruises documented without investigation. Another resident, with moderate cognitive impairment, also had several bruises noted, but no investigation was initiated. The Director of Nursing confirmed the lack of investigations, violating the facility's abuse prevention policy.
A resident with a documented need for a mechanical lift due to fall risk factors was improperly transferred using a gait belt by a CNA, resulting in a fall in the shower room. The resident's care plan specified the use of a mechanical lift for all transfers, which was not followed, leading to the incident.
Failure to Timely Notify Provider of Acute Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to provide timely notification to a resident's provider regarding an acute change in condition. The facility's policy requires immediate notification of the attending physician, resident representative, and supervisory staff when a resident experiences a significant change in condition, such as symptoms of stroke or sudden decline. In this case, a cognitively intact female resident with a history of postprocedural hemorrhage, repeated falls, tinea pedis, and encephalopathy began experiencing increased left leg weakness and vision problems. These symptoms were new and represented a significant change from her baseline, as she typically did not require assistance with ambulation or transfers. On the day of the incident, the resident reported worsening vision and left leg weakness, requiring two staff members to assist her to the bathroom, which was out of character for her. Both CNAs who assisted her recognized the change and notified the LPN on duty. Despite these new symptoms and the resident's complaints, the LPN decided to monitor the resident rather than immediately notify the provider, citing that the nurse practitioner had seen the resident the previous day for similar but less severe complaints. The LPN did not call the physician or nurse practitioner at that time, even though the resident's condition continued to deteriorate throughout the day. It was only after the resident developed additional symptoms, including flaccidity of the left arm and further decreased mobility, that the LPN contacted the nurse practitioner and arranged for the resident to be sent to the emergency department. Hospital records confirmed the resident had suffered an acute ischemic stroke. Interviews with staff and the resident confirmed that the provider was not notified promptly when the significant change in condition first occurred, resulting in a delay in evaluation and treatment.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for two residents, as required by its own infection prevention and control policy. According to the policy, EBP, which includes the use of gown and gloves, must be used for all residents with wounds, regardless of the presence or amount of drainage. However, during wound care observations for two residents—one with a history of atherosclerosis, chronic kidney disease, and hypertension, and another with systemic scleroderma and open areas on her foot—the registered nurse only wore gloves and did not use a gown. The nurse stated that EBP was not used because the wound drainage had never soaked through the dressing and there was no diagnosis of a multidrug-resistant organism (MDRO). Further confirmation from the Director of Nursing indicated that EBP should be used for every resident with a wound, regardless of whether the drainage is contained. The failure to follow the facility's EBP policy was identified through observation, interview, and record review, and involved two out of three residents reviewed for wound care.
Failure to Document Involuntary Discharge of Resident
Penalty
Summary
The facility failed to provide necessary documentation by a physician regarding the involuntary discharge of a resident, identified as R1, following hospitalization. R1 was initially sent to the emergency room due to combative behaviors, hallucinations, and increased paranoia, and was subsequently admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. Despite these circumstances, the facility did not document the basis for R1's involuntary discharge, including the reasons why R1 should not return to the facility, what needs could not be met, the facility's efforts to meet those needs, and the specific services the receiving facility could provide. Interviews revealed that neither R1's primary physician nor the covering nurse practitioner was consulted about the decision not to readmit R1, resulting in a lack of documentation in R1's medical record. The facility's administrator confirmed the absence of an involuntary discharge policy and acknowledged the lack of physician documentation regarding the discharge decision. This oversight highlights a significant deficiency in the facility's discharge process, as it failed to comply with the required documentation and communication protocols.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide timely written notification of discharge to a resident, the resident's representative, and the Ombudsman, as required by the Ombudsman's Residents' Rights policy. The policy mandates that residents must receive a written notice detailing the reasons for discharge, how to appeal the decision, and a stamped and addressed envelope for mailing the appeal. In this case, a resident was sent to the emergency room due to combative behaviors and was later admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. Despite discussions among facility staff about the resident's condition and the decision not to readmit the resident, no written notice of discharge was provided to the resident, the resident's family member, or the Ombudsman. The resident's medical record lacked documentation of the discharge notice, including the reasons for the involuntary discharge, the needs that could not be met at the facility, the facility's efforts to meet those needs, and the services the receiving facility could provide. Interviews with the resident's family member, the facility administrator, and the Ombudsman confirmed that no written notice was given. The Ombudsman emphasized the importance of receiving such notices to assist residents and their families in understanding their appeal rights and ensuring proper placement in another facility.
Failure to Provide Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident and the resident's representative upon the resident's transfer to the hospital. The facility's Bed Hold and Readmission Policy, dated 10-26-18, requires that a written copy of the bed-hold policy be provided to the resident at the time of transfer for hospitalization or therapeutic leave. However, for one of the three residents reviewed for bed hold notice, there was no documentation in the medical record indicating that a bed hold notice was given to the resident or the resident's family member after the resident was sent to the hospital. The resident's family member confirmed that they were not given a bed hold notice and were unaware of what the notice entailed. The Director of Nursing acknowledged that the facility did not send a bed hold notice to the family member and confirmed the absence of documentation in the resident's medical record.
Deficiencies in Dishwashing and Handwashing Practices
Penalty
Summary
The facility failed to adhere to its own policy regarding the use of Heat Stickers to ensure that dishes reach the required surface temperature during the rinse cycle in the dish machine. The Assistant Dietary Manager admitted to not using the Surface Temperature Stickers, which were discarded after becoming outdated. Instead, a thermometer was used in the dish machine, but this method does not confirm if the appropriate surface level of heat for dishes, utensils, and glasses is achieved. The Dietary Manager acknowledged the necessity of using the stickers and committed to ordering them. Additionally, the facility did not have a specific handwashing policy for kitchen staff, particularly between handling dirty and clean dishes. An observation revealed that a Dietary Aide used a sanitation solution instead of washing hands with soap and water after handling dirty dishes and before handling clean ones. The Assistant Dietary Manager noted the absence of a handwashing sink in the dish room and mentioned that staff were instructed to wash hands in the kitchen, which was not being followed. This oversight has the potential to affect all 101 residents in the facility.
Failure to Report Bruises of Unknown Origin
Penalty
Summary
The facility failed to report bruises of unknown origin to the State Agency for two residents, which is a violation of their Abuse Prevention Program Facility Policy. The policy mandates that any reasonable suspicion of a crime against a resident, including injuries of unknown source, must be reported to the state survey agency within specified time frames. For Resident 35, who is severely cognitively impaired, bruises were noted on two separate occasions: a ten-centimeter round dark purple bruise on the right hip and a nine-inch by eight-inch bruise on the left inner thigh. Both events were unwitnessed, and the Director of Nursing confirmed that these bruises were not reported to the Illinois Department of Public Health (IDPH). Similarly, Resident 81, who has moderate cognitive impairment, was found with multiple bruises of unknown origin, including a dark purple bruise on the back of the right leg, bruising with redness on the right upper leg, and several discolorations on both arms. The resident was unable to explain how the bruises occurred, and the Director of Nursing assumed they might have resulted from assistance by a family member. However, no notification was sent to the State Agency to report these bruises, which constitutes a failure to comply with the facility's internal reporting requirements.
Failure to Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to initiate abuse investigations for bruises of unknown origin for two residents, R35 and R81, as required by their Abuse Prevention Program Facility Policy. R35, who is severely cognitively impaired, was found with a ten-centimeter round dark purple bruise on the right hip and a nine-inch by eight-inch bruise on the left inner thigh on separate occasions. These bruises were documented in the progress notes and event reports, but no abuse investigation was conducted. The Director of Nursing confirmed that no investigations were initiated for these incidents. Similarly, R81, who has moderate cognitive impairment, was found with multiple bruises of unknown origin, including a dark purple bruise on the back of the right leg, bruising with redness on the right upper leg, and several discoloration areas on both arms. These findings were documented in the nursing notes and event reports, but again, no abuse investigation was conducted. The Director of Nursing acknowledged the lack of investigation for R81's bruises. The facility's failure to investigate these incidents is a violation of their policy, which mandates investigations for all incidents involving potential abuse.
Failure to Use Mechanical Lift Results in Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident during a shower, resulting in a fall. The resident, identified as R45, had a documented decline in strength and independence during transfers and was assessed to require a mechanical lift for all transfers due to increased fall risk factors such as impaired cognition, poor safety awareness, diuretic use, and weakness. Despite these documented needs, the resident was not transferred using the mechanical lift as required. On the morning of the incident, a Certified Nursing Assistant (CNA), identified as V10, wheeled the resident into the shower room and attempted to assist the resident to stand using a gait belt instead of the mechanical lift. This improper method led to the resident's knees buckling, resulting in a fall. The Assistant Director of Nursing confirmed the incident and noted that the CNA did not use the proper equipment for the transfer, which was a deviation from the resident's care plan and the facility's fall prevention program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Quincy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blessing Hospital Snu | 1.2 mi | ★★★★★ | 0 | 0 |
| Sunset Home | 1.6 mi | ★★★★★ | 4 | 2 |
| Quincy Healthcare & Sr Living | 2.6 mi | ★★★★★ | 2 | 0 |
| Maple Lawn Nursing Home | 11.9 mi | ★★★★★ | 23 | 0 |
| Luther Manor Retirement & Nursing Center | 13 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.