Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 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.
Failure to prevent and treat pressure ulcers: A resident admitted with COPD and pneumonia had a Braden score indicating pressure injury risk, but the initial care plan did not include pressure-relieving interventions. The resident later developed two stage 2 pressure ulcers on the buttocks, with wound care not started until after the wounds were identified and the pressure ulcer care plan not initiated until several days later. The resident was observed sitting in a wheelchair with direct pressure on the buttocks and no offloading, and staff verified the wounds were caused by pressure.
A resident with Alzheimer's disease, macular degeneration, and impaired cognition was assessed as needing supervision and assistance with footwear and increased fall supervision, but staff did not ensure her shoes were worn properly. She later had an unwitnessed fall in her room, developed swelling, bruising, and deformity of the R wrist, and was diagnosed with a distal radius fracture requiring a cast. The DON stated the fall investigation was incomplete and that staff should always assist the resident with putting on and removing her shoes.
Dishwasher Failed to Sanitize Dishes Properly: The Dietary Manager observed the back dish machine failing to reach the required high-temp final rinse when temperature sensor labels did not turn black on two separate tests. The machine was then switched to chemical sanitation, but chlorine strips never changed color during four loads, and the Dietary Manager confirmed the dishwasher was used for all dirty dishes in the facility.
Failure to prevent abuse between two residents with severe cognitive impairment. One resident with dementia and agitation repeatedly kicked another resident in a wheelchair, and the other resident struck back in the face. Staff and witness statements described the altercation as intentional, with repeated kicking and smacking before the residents were separated.
Failure to document justification and monitoring for antipsychotic use. The facility did not have documented diagnoses, target behaviors, or antipsychotic evaluations to support psychotropic use for two residents. One resident’s Risperdal dose was increased without charted behaviors or non-pharmacological interventions, and another resident’s Seroquel use lacked measurable behaviors and care plan support. An ADON and DON confirmed the facility did not complete evaluations before antipsychotics were started.
The facility failed to report a bruise of unknown origin on a resident with depression, anxiety, Parkinson’s disease, and wheelchair dependence, and also failed to report a missing silver cross necklace belonging to a cognitively impaired resident with dementia. Staff documented the thigh bruise and the missing item, but the records did not show notification to the abuse coordinator or reporting to the state agency, and the DON and administrator confirmed the events were not reported as required.
The facility failed to complete abuse investigations for two residents. One resident, who was wheelchair dependent and required extensive ADL assistance, had a healing bruise on the inner thigh with no documented investigation or notification, even though staff and the DON stated an unusual bruise location should be investigated. Another resident’s missing silver cross necklace was reported and searched for, but there was no documented investigation, staff interviews, or resolution, and the Administrator stated she did not investigate the missing item.
Failure to Submit Discharge MDS Assessments: The facility did not complete or submit discharge MDS assessments for two residents after one resident died in the facility and another was discharged to another facility. Record review showed no evidence of the required discharge MDSs in the EHR or MDS tracking log, and the DON verified the assessments were never completed or submitted.
A resident’s PASRR Level I screen showed no PASRR condition, but after admission the resident was diagnosed with vascular dementia with psychotic disturbance and started on Seroquel for paranoia, delusions, and agitation. The ADON stated she was not aware a new PASRR was needed when a psychiatric dx was added and psychotropic meds were initiated, and the record showed no new PASRR Level I screen or Level II referral.
A resident’s comprehensive care plan was not updated to reflect new psychiatric dx, psychotropic med use, target behaviors, or non-pharmacological interventions. The resident had dementia with psychotic disturbance, depression, anxiety, restlessness, agitation, delusions, and paranoia, and was receiving Seroquel for behaviors toward staff, but the care plan lacked measurable behavior descriptions and behavioral interventions.
A resident with pneumonia, CHF, SOB, and wheezing had orders for PRN O2 and scheduled albuterol nebulizer treatments, but the initial and current care plans did not include oxygen or nebulizer care. Staff observed the nebulizer mask left on the bedside table instead of stored in a plastic bag between uses, and the CNA, DON, and ADON all confirmed the mask storage expectation and the missing respiratory care plan.
Unlabeled multidose medications were found in medication storage when an opened Lidocaine vial and an opened insulin Lispro pen lacked resident names and dates opened. An RN confirmed the Lidocaine was being used for one resident and the Lispro pen for another resident, while the ADON stated multidose vials and insulin pens should be labeled with the date opened, resident name, and expiration date.
Failure to use required infection control precautions during wound and incontinence care: an LPN provided coccyx wound treatment to a resident with a stage 2 pressure wound without a gown, and a CNA performed incontinent care without a gown and reused soiled gloves to apply a brief, dress the resident, and reposition the resident. The IP stated the wound was open and staff should have used clean techniques during wound and incontinence care.
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 Prevent and Treat Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for R79, who was admitted with COPD and pneumonia and had a Braden Scale score of 17, indicating risk for pressure ulcer development. On admission, the evaluation documented no redness, rashes, lesions, excoriations, or pressure ulcers, and the initial care plan did not include any pressure-relieving interventions despite the resident being identified as at risk. Facility policy required completion of the Braden assessment on admission and implementation of the corresponding risk protocol, including repositioning and other preventive measures. R79 developed two stage two pressure ulcers on the buttocks after admission. The skin integrity report documented a stage two pressure ulcer on the right buttock and a stage two pressure ulcer on the left buttock, both discovered on 2/6/26 at 1:30 PM. Nursing documentation described a ruptured blister on the right buttock measuring 3 cm by 3 cm by 0.1 cm and a partial thickness wound on the left buttock measuring 2.5 cm by 3.5 cm. The nurse practitioner stated the wounds were caused by pressure, and the infection preventionist/RN stated the wounds were caused by pressure as well. The pressure ulcer care plan was not initiated until 2/9/26, even though the wounds were identified on 2/6/26. Treatment was also not started until 2/8/26, with orders to cleanse the wounds and apply Xeroform and sacral foam dressings. During observation, R79 was seen sitting in a wheelchair with direct pressure on the buttocks and no offloading. The resident stated she had sores on her bottom since coming to the facility, and family members reported delays in call light response and concern that the resident may have been left sitting in a wet brief.
Failure to Supervise Footwear Use and Complete Fall Investigation
Penalty
Summary
The facility failed to provide adequate supervision and assistance with footwear for a resident with Alzheimer's disease, anxiety, chronic respiratory failure, and age-related macular degeneration who was assessed as needing supervision/touching assistance with putting on and taking off footwear. The resident's care plan identified her as at risk for falls and directed staff to provide increased supervision, non-skid shoes/socks, and assistance with dressing due to her limited ability to dress herself, weakness, and macular degeneration. The resident was also noted to have moderately impaired cognition and to require supervision/touching assistance with footwear. The resident suffered an unwitnessed fall in her room after last being seen heading to her room from an activity. The fall event documented that her shoes were not worn properly, with the backs pressed down as if slipped on, and that she had pain and swelling in her right wrist. The next day, nursing documented swelling, warmth, bruising, and deformity of the right wrist, and the resident returned from an orthopedic walk-in clinic with a diagnosis of a right distal radius fracture requiring a cast. The DON stated there was not a complete fall investigation with witness statements for the fall and confirmed staff should always assist the resident with applying and removing her shoes and that she required frequent supervision as part of her fall prevention plan.
Dishwasher Failed to Sanitize Dishes Properly
Penalty
Summary
The facility failed to ensure that the dishwashing machine was effectively sanitizing dishes. The facility’s CMS Form 671 documented 91 residents in the building, and the dietary policy required the department supervisor or designees to check dish machine temperatures during meals, with heat stickers used to verify that the dish machine and pot/pan machine reached acceptable temperatures. The manufacturer instructions stated the final rinse temperature should be 180 degrees to 195 degrees Fahrenheit, and the temperature sensor label instructions directed that the label should turn from silver to black when the proper surface temperature was reached. During observation, breakfast dishes were being washed through the back dishwasher while the Dietary Manager stated it was a high-temperature dish machine and the final rinse should reach 180 degrees Fahrenheit. A temperature sensor label placed on a plate did not turn black as it came out of the machine, indicating the final rinse did not reach 180 degrees Fahrenheit. A second label was run through the machine and also did not turn black. The Dietary Manager then turned off the booster heater and used the chemical sanitation function, but during four loads of dirty dishes the chlorine strip never changed color to show the sanitation level was proper, and the strip was not even changing color when tested in the spray of the final rinse. The Dietary Manager stated the dishwasher was used for all dirty dishes from the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for two residents involved in a physical altercation in the common area. The facility’s Abuse Prevention Program Policy states residents have the right to be free from abuse, neglect, and mistreatment, and defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The incident involved two severely cognitively impaired residents: one resident with unspecified dementia and cognitive communication deficit, and another resident with dementia with mood disturbance, agitation, anxiety, and restlessness. According to the investigation and staff statements, one resident was sitting in a wheelchair in the common area when the other resident approached and kicked her, making contact with her leg. In response, the first resident struck the other resident in the face with the back of her hand. Progress notes and witness statements described repeated kicking and striking between the two residents, with staff separating them after the altercation. One witness stated the kicking and smacking were intentional, and another staff member reported the residents had to be separated to keep the situation deescalated.
Failure to Document Justification and Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to document appropriate diagnoses and target behaviors to support the use of antipsychotic medications for two residents, and failed to document behavioral interventions before increasing an antipsychotic dose. The facility’s psychotropic medication policy required a specific diagnosis, documented target behaviors, prior non-pharmacological interventions, and periodic reassessment, but the record review showed these elements were not consistently present for the residents reviewed. For one resident, the record showed severe cognitive impairment, no behaviors on the MDS, daily antipsychotic use, and no gradual dose reduction attempt. The resident had Risperdal ordered for unspecified dementia with agitation, later reduced, then increased again after a hospice nurse reported delusional statements and assaultive behavior. However, the electronic record did not include documentation of increased behaviors or non-pharmacological interventions before the dose increase, and the chart contained no antipsychotic drug evaluations. Staff also verified that the resident did not have documented behaviors or a diagnosis to justify the Risperdal use or the increase. For another resident, Seroquel was ordered for vascular dementia with psychotic disturbance, later changed to a lower noon dose for delusions and agitation. The record did not include antipsychotic drug evaluations, and the care plan lacked documented target behaviors, measurable descriptions of paranoia, agitation, or delusions, as well as non-pharmacological interventions or individualized behavioral monitoring. The assistant director of nursing stated the resident was started on Seroquel for paranoia and behaviors toward staff, but the facility did not complete evaluations before starting antipsychotic medications and relied on information from staff when prescribers wrote the orders.
Failure to Report Injury of Unknown Origin and Missing Resident Property
Penalty
Summary
The facility failed to report a bruise of unknown origin and an allegation of misappropriation of resident property to the appropriate authorities. The facility’s Abuse Prevention Program policy required staff to immediately report any suspicion of abuse, neglect, exploitation, or misappropriation of resident property, and to report injuries of unknown source and misappropriation of resident property to the state agency within the required timeframe. Despite this policy, R84, who had diagnoses including depression, anxiety, Parkinson’s disease, and wheelchair dependence, was noted in a nursing progress note to have a healing bruise on the inner left thigh with no pain or discomfort, and the record did not document notification to the abuse coordinator or reporting to the state agency. Staff later confirmed the thigh bruise was in an unusual location and that no report for injury of unknown source had been sent. The facility also did not report a missing silver cross necklace belonging to R82 to the state agency. R82 had dementia and was cognitively impaired. A grievance/concerns/missing item form documented that the necklace was missing, that the resident’s room and multiple other areas of the facility were searched, and that the item could not be located. The resident’s family member was notified and stated appreciation for the search efforts, but the administrator later stated she was aware of the missing necklace and did not report the missing item to the state agency.
Failure to Investigate Injury of Unknown Origin and Missing Jewelry
Penalty
Summary
The facility failed to complete abuse investigations for two residents reviewed for abuse concerns. The facility’s Abuse Prevention Program policy stated that any incident or allegation involving abuse, neglect, or misappropriation would result in an abuse investigation, and that an injury of unknown source includes an injury that was not observed or could not be explained and is suspicious because of its location or extent. For one resident, who had depression, anxiety, Parkinson’s disease, was wheelchair dependent, and required extensive assistance with some ADLs, nursing documented a healing bruise to the inner left thigh with no further investigation, observation, or notification in the electronic record. Staff stated that bruises in unusual locations such as the thigh should be reported to the Administrator and investigated, and the DON confirmed she was not notified and had no investigation for the January bruise. For another resident, a grievance form documented that a silver cross necklace was missing and that the resident’s room and multiple common areas were searched, but the item was not found. The resident’s family member stated the necklace was sentimental and reported it missing. The electronic medical record did not document an investigation, staff interviews, or a resolution for the missing necklace, and the Administrator stated she was aware of the missing necklace but did not investigate it.
Failure to Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to submit discharge MDS assessments for two residents after they left the facility. Record review showed that R40 died in the facility, but the Electronic Health Record and MDS Tracking Log did not contain evidence that a discharge MDS was completed or submitted after the death. Record review also showed that R90 was discharged to another facility, but the Electronic Health Record and MDS Tracking Log did not contain evidence that a discharge MDS was completed or submitted after the discharge. The facility policy states that discharge assessments are to be completed and transmitted in accordance with required timeframes, and the DON verified that the MDS Coordinator was supposed to submit an MDS assessment whenever a resident is discharged from the facility and that R40 and R90’s discharge MDS assessments were never completed or submitted.
Failure to Complete New PASRR Screening After Psychiatric Change
Penalty
Summary
The facility failed to ensure a resident received a new PASRR Level I screening and referral for a Level II evaluation after a significant change in condition. The resident’s PASRR Level I screen dated 11/22/24 stated that no disability was present and noted that if changes occurred or new information refuted those findings, a new screen must be submitted. After admission, the resident was later given a diagnosis of Vascular Dementia with Psychotic Disturbance and was started on Seroquel 25 mg daily on 1/2/25. The resident’s record also showed a later physician order dated 6/6/25 for Seroquel 12.5 mg at noon daily for Delusions and Agitation. The ADON stated the resident had been started on Seroquel for paranoia and behaviors toward staff, but she could not find documentation of behaviors toward other residents or self. She also stated she was not aware that a new PASRR was needed when a psychiatric diagnosis was added and psychotropic medication was initiated after admission, and confirmed that new PASRR screenings were not being completed under those circumstances. The resident’s record contained no evidence that the facility submitted a new PASRR Level I screen or referred the resident for a Level II evaluation after the psychiatric diagnosis and psychotropic medication were added.
Care Plan Not Updated for Psychiatric Changes and Psychotropic Use
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for one resident to reflect significant changes in condition, including new psychiatric diagnoses, initiation of psychotropic medication, identification of target behaviors, and use of non-pharmacological interventions. The resident was admitted on 11/25/24 and had physician orders for Seroquel 25 mg daily for Vascular Dementia with Psychotic Disturbance and later Seroquel 12.5 mg at noon daily for Delusions and Agitation. The current comprehensive care plan did not document target behaviors, did not provide a measurable description of paranoia, agitation, or delusions, and did not include non-pharmacological interventions attempted prior to or in conjunction with psychotropic medication use. The resident’s medical diagnosis list included Depression, Anxiety Disorder, Restlessness and agitation, Vascular Dementia with Psychotic Disturbance, and Unspecified severe Dementia with Psychotic Disturbance. The Assistant Director of Nursing stated the resident was initially started on Seroquel for paranoia and behaviors toward staff and confirmed the initial care plan for mood and psychotropic drug use was initiated, but it did not include target behaviors or non-pharmacological interventions. The ADON stated the care plan should be revised with changes and should include non-pharmacological interventions and targeted behaviors.
Respiratory Equipment Not Properly Stored and Care Plan Missing for Oxygen/Nebulizer Use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who was admitted with diagnoses including pneumonia, chronic diastolic congestive heart failure, shortness of breath, and wheezing. The resident had physician orders dated 2/6/26 for oxygen at 2 liters as needed and Albuterol Sulfate nebulization 2.5 mg/3 ml one vial three times a day. The resident’s initial care plan for respiratory care documented oxygen and nebulizer treatments as not applicable, and the current care plan did not include oxygen or nebulizer treatments. During observation on 2/23/26, the resident was sitting in a wheelchair in the room wearing oxygen, and the nebulizer mask was on the bedside table rather than stored in a bag. The mask remained on the bedside table during a later observation the same day. A CNA verified the mask was not stored in a bag and stated it should be cleaned and stored in the plastic bag, while the nurses take care of the nebulizer treatments and masks. The DON stated nebulizer masks are to be kept in a plastic storage bag any time they are not in use, and the ADON verified there was not an initial care plan for the resident’s oxygen or nebulizer treatments even though there should have been.
Unlabeled Multidose Medications Found in Medication Storage
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when an opened multidose vial of Lidocaine HCL 1% and an opened multidose insulin Lispro injector pen were found without resident identifiers or dates opened. The facility’s policy required centrally stored prescription medications to be labeled with the resident’s name, medication name, strength, and quantity, and stated that each vial must be marked with the date it was opened. The report identified that the insulin was ordered for a resident with Type II Diabetes Mellitus and that the Lidocaine vial was being used for another resident. During observation of the 500-hallway medication cart and medication room, surveyors found the opened Lispro injector pen and the opened Lidocaine vial lacking labels with the resident names and the dates opened. An RN stated she had used the Lidocaine for one resident and confirmed it was not labeled with that resident’s name or the date opened. The RN also verified the Lispro injector pen was being used for another resident and did not have a label with that resident’s name or the date the pen was opened. The ADON later stated that all multidose vials and insulin multidose injector pens should be labeled with the dates they are open, residents’ names, and expiration dates.
Failure to Use Required Infection Control Precautions During Wound and Incontinence Care
Penalty
Summary
The facility failed to implement infection prevention and control precautions for one resident with an open wound. The report states that the Enhanced Barrier Precautions sign required staff to clean their hands before entering and when leaving the room and to wear gloves and a gown for high-contact resident care activities, including wound care, hygiene, and changing briefs or assisting with toileting. The facility’s Enhanced Barrier Precautions guidance also described gown and glove use during high-contact care activities, and the incontinence/perineal care policy directed staff to remove soiled gloves, wash hands, and don clean gloves before applying an incontinent pad. On 2/25/26 at 10:45 AM, an LPN provided pressure ulcer treatment to the resident’s coccyx and did not wear a gown while caring for a stage two pressure wound. The LPN stated that a gown was not worn because staff had been told it was not needed this time, although it had been required previously for the same wound. At 10:50 AM, a CNA performed incontinent care while wearing gloves but no gown, washed the resident’s groin area, then used the same soiled gloves to place a new adult brief, pull up the resident’s pants, and reposition the resident in bed. The CNA stated that a gown should have been worn because the resident had an open wound and that the gloves should have been removed and hands washed before continuing care. At 11:15 AM, the Infection Preventionist stated the resident was not placed in EBP because the wound was stage two, had no slough, and did not look infected, and verified that the wound was open and staff should have used clean techniques during wound and incontinence care.
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 | ★★★★★ | 1 | 0 |
| Quincy Healthcare & Sr Living | 2.6 mi | ★★★★★ | 12 | 0 |
| Maple Lawn Nursing Home | 11.9 mi | ★★★★★ | 22 | 0 |
| Luther Manor Retirement & Nursing Center | 13 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.