Good Samaritan Home: Stroke Symptoms Ignored for Days - IL
By the time staff finally sent her to the hospital, she couldn't move her left arm either.
The sequence of events, documented in a September 19, 2025 complaint inspection, describes a resident referred to as R1, an independent woman who almost never used her call light. That detail matters, because when she pressed it one day between 11:00 and 11:30 in the morning, two nursing assistants immediately understood something was wrong.
"It was weird that she had her call light on because she is independent and never uses her call light," said V12, a certified nursing assistant, in a statement recorded by inspectors. V12 and a colleague, V11, went to R1's room together. R1 told them her eyes were bothering her, that she couldn't see the way she normally could, and that she couldn't really move her left leg.
They helped her to the bathroom. Getting her there required guiding her left leg manually. V11 went to find the floor nurse.
The nurse on duty that day was V9, an agency licensed practical nurse. According to V12, V9 came to the room and told R1 that her nurse practitioner was already aware of her complaints from the day before, and that V9 would monitor her. Then V9 left.
V12 was pulled to another unit for several hours. When V12 returned to the floor around 3:00 in the afternoon, V9 asked for help getting R1 to the bathroom again. When V12 got to the room, R1 said she now could not move her left arm.
Shortly after that, R1 was sent to the hospital.
What V9 had documented in R1's chart told a different story than what had actually unfolded. Inspectors found that V9 had typed everything that happened across the entire day into a single progress note, entered just before R1 was transferred out. The note did not reflect the times when R1 had actually reported her symptoms. V9 confirmed this to inspectors, acknowledging she had consolidated the day's events into one entry rather than documenting them as they occurred.
The problems had started earlier than that morning. R1's nurse practitioner, V4, told inspectors she had seen R1 at the facility on September 10. At that visit, R1 reported leg cramps that were worse at night and vision changes. V4 said R1 could move her left leg up and down without difficulty at that point, and V4 initiated orders to address the leg cramps. There were no stroke-like symptoms.
But by September 11, according to the Director of Nursing, R1 was already requiring more help with daily activities and complaining of increased weakness and worsening vision. Nobody called V4 or R1's physician that day.
"I would have expected the facility to notify me or myself right away if R1 was experiencing increased weakness or required more assistance with ADLs," V4 told inspectors, referring to activities of daily living.
The Director of Nursing, V2, said the same thing. She told inspectors on the morning of September 19 that she would have expected a nurse to contact R1's provider immediately when R1 first showed significant changes in her condition, which was September 11, eight days before the inspection and the day R1 was finally hospitalized.
That gap, from the first signs of deterioration to the phone call that never came, is what inspectors cited as actual harm.
The inspection report assigns the deficiency its most serious harm level. R1 had been independent. She had not needed help walking to the bathroom or moving her limbs. Within a matter of days, she needed two people to guide her leg onto a toilet, and by afternoon she had lost the use of her arm entirely.
V9 knew, by her own account, that R1's nurse practitioner had been told something the day before. That knowledge became a reason not to call again, not a reason to call with urgency about a woman who could no longer move her left side.
V12 didn't know how R1 got back to her room after lunch. She had been sent to another unit. When she came back, R1 had gotten worse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Home from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 28, 2026 · Our methodology
GOOD SAMARITAN HOME in QUINCY, IL was cited for violations during a health inspection on September 19, 2025.
By the time staff finally sent her to the hospital, she couldn't move her left arm either.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.