Inspection·April 24, 2023

F 0602 24ml. Investigation initiated and is ongoing. (Local Lae Enforcement) is here at present time and notified. Level of Harm - Minimal harm or potential for actual harm On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated that once the allegation of missing Morphine was reported by V4 on 4/3/23, the remaining bottle of Morphine Sulfate oral solution belonging to R3 was pulled out of the medication cart. V2 stated that R1 should have had two bottles of Morphine, R2 should have had one bottle, and R3 should have had one bottle in the drawer but three of the four bottles were missing. V2 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she did not report this discrepancy to V1 as part of the diversion of narcotics investigation which was started on 4/3/23. Residents Affected - Few R3's Controlled Substance Record which records doses remaining in R3's bottle of Morphine Sulfate liquid 20mg/ml dated as dispensed 3/20/23 documents that as of 4/4/23 V4 was the last to sign this document when V4 administered 0.25ml of Morphine (5mg) to R3 with a volume of 27ml recorded as still in the bottle. On 4/24/23 at 1:56p.m. V4 stated that she was R1, R2, R3's nurse on Friday 3/31/23 for the day shift. V4 stated that there were four bottles of Morphine Sulfate oral medication stored in the locked narcotics box of the medication cart, two for R1, one each for R2 and R3 during her shift-to-shift narcotic count with V8 (RN). V4 stated that during the shift-to-shift narcotic count on 4/3/23 with V5 (Licensed Practical Nurse/LPN), which was the next time V4 worked, R1 and R2's three Morphine Sulfate bottles were missing along with their controlled substance record used to log the doses removed from the bottle. V4 stated she refused to sign the shift-to-shift narcotics count log because she knew those medications might have been diverted. V4 stated she reported her suspicion to V2. V4 stated that the remaining Morphine Sulfate bottle in the cart belonging to R3 was removed and given to V2 during the investigation. V4 stated that V5 stated she noticed there weren't as many Morphine bottles as the last time she worked, but that V5 thought the medications were discontinued. V4 stated that nurses are supposed to put the bottles of liquid morphine on a flat surface to measure the remaining volume in the bottles in order to properly reconcile the narcotics count. V4 stated that she and the other nurses had not been verifying the quantity of Morphine left in each bottle but, instead, they were just verifying the number of bottles present. On 4/24/23 at 10:50a.m. V7 (LPN) stated that she worked the day shift as R1, R2, R3's nurse on 4/1/23 and 4/2/23. V7 stated that on 4/1/23 she and V8 counted the narcotic drawer during the morning shift-to-shift narcotic count. V7 stated there was only one bottle of Morphine locked in the narcotic drawer at that time. V7 stated she had worked on 3/27/23 on the same hallway but does not recall how many bottles of Morphine were in the narcotics box on that date. On 4/24/23 at 5:35p.m. V8 stated he worked the night shift on 3/31/23. V8 stated when he counted the Morphine bottles with V7 at approximately 6:00a.m. 4/1/23, he thinks there were three bottles. On 4/19/23 at 9:00a.m. and 10:32a.m. and on 4/24/23 at 12:40p.m. V1 (Administrator) stated that on 4/3/23 V4 came in to work the day shift at 6:00a.m. after having last worked on 3/31/23. V1 stated that V4 noted on Monday 4/3/23 during the shift-to-shift narcotic count there was only 1 bottle of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 2 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Morphine Sulfate left in the medication cart which belonged to R3. V1 stated that V4 refused to take over the medication cart on 4/3/23 because she had counted four bottles of Morphine Sulfate belonging to R1, R2 and R3 when she worked 3/31/23 and V4 knew that none of those residents would have used that much morphine over the weekend. V1 stated that after V4 alerted the facility there were narcotics not accounted for, V2 (Director of Nurses) proceeded to search through the medication carts, residents' rooms, and the nurses' station to find the missing medications. V1 stated that whoever took the Morphine also took the Controlled Substance Records for each bottle making it hard to determine how much morphine was taken for sure. V1 stated there were five nurses who worked between 3/31/23 to 4/3/23 using that medication cart and all were interviewed. V1 stated that based on their interviews, two nurses who gave conflicting accounts of how many bottles of Morphine were in the narcotic drawer were suspected of having diverted the medication during their shifts 3/31/23 and 4/1/23. V1 stated that on the afternoon of 4/3/23 after an exhaustive search for the missing bottles of Morphine concentrate and after interviewing nursing staff, V1 formed a suspicion that the three missing bottles of Morphine were stolen or diverted. V1 stated that the original investigation was for R1 and R2's missing bottles of Morphine, but that she had been informed on 4/16/23 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated she initially watched the facility's security video footage of 3/31/23 when V8 worked the night shift, and on 4/1/23 when V7 worked the day shift. V1 stated she noted that on 4/1/23 V7 took the medication cart into R3's room and closed the door on two different occasions. V1 stated that in the afternoon of 4/1/23, V7 took her medication cart in to R3's room for approximately 40 minutes while R3's door was closed. V1 stated that nurses do not normally take medication carts into residents' rooms. V1 stated that she also did not understand why V7 would close R3's door if V7 was administering medications. V1 stated that she reviewed R3's controlled substance record and Medication Administration Records (MARS) for 4/1/23 and saw that V7 documented that she administered 0.25ml of Morphine Sulfate to R3 at 7:00a.m. and again at 11:40 in the morning. V1 stated that she compared the video times of V7 passing medications to R3's controlled substance record and found that V7 did not go into R3's room at or around 7:00a.m. or 11:40a.m. V1 stated that V7 did not go into R3's room until 8:47a.m. and exited at 9:03a.m. V1 stated the next time V7 entered R3's room was at 1:00p.m. where V7 remained for 40 minutes with the door closed. V1 stated that because V7's documented Morphine administration times did not match the video times, V1 decided to watch the video from the previous time V7 worked on R1, R2, R3's unit, which was 3/27/23. V1 stated the video camera only records video from the hallway in front of R3's room, therefore, V1 could not determine if V7 entered R1 or R2's room to administer any medications. V1 stated that R1 and R2 have Morphine ordered but do not generally experience pain and, therefore, do not usually use any Morphine. V1 stated that R1 and R2's Morphine bottles, and the controlled substance records that go with each bottle are missing, so if V4 had not noticed the three bottles of Morphine were missing 4/3/23, it may have been a longer period of time before the facility realized diversion of narcotics had occurred. V1 stated that on 3/27/23 V7 documented that she administered Morphine Sulfate to R3 at 7:10a.m. and 1:00 in the afternoon. V1 stated the video shows that V7 did not go into R3's room at 7:00a.m. to administer any medication but that V7 did enter R3's room at 8:47 that morning. V1 stated that on 3/27/23 at 1:00p.m., the video shows that V7 placed a pill in a medication cup but never took the bottle of Morphine out of the locked drawer to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 3 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete prepare a dose for R3. V1 stated the video shows V7 taking only the cup with a pill into R3's room but no liquid Morphine Sulfate as was documented. On 4/24/23 at 11:26a.m. V11 (Sheriff's Deputy) stated he is investigating a diversion of Morphine Sulfate oral medications from the facility. V11 stated that he and the facility narrowed the suspects down to two nurses but cannot determine which one diverted the medication. V11 stated that V7's urine toxicology was negative for opioids but V8's urine toxicology report was positive. V11 stated that both V7 and V8 have prescriptions for opioid medications related to pain, and both V7 and V8 have a documented allergy to Morphine. V11 stated that both nurses denied having diverted any medications. V11 stated that, for now, he knows a diversion occurred but cannot prove who did it. Event ID: Facility ID: 145726 If continuation sheet Page 4 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on observation, interview and record review the facility failed to immediately report diversion of controlled substances to local law enforcement or the State Agency for three of three residents (R1, R2, R3) reviewed for reporting of alleged violations in a sample of five. Findings include: A Facility Abuse Policy dated as revised 2/2020 states, When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify (The State Agency) immediately. This policy states, If there is a reasonable suspicion that a crime has been committed, and that, does not involve serious bodily injury, then report to local law enforcement as soon as possible but within 24 hours of when the suspicion was formed. A Facility Incident Report Form with a fax cover sheet dated 4/6/23 and with an occurrence date of 4/6/23 documents that an initial report was sent to the State Agency on that date because, RN (Registered Nurse) staff nurse reported that R1 and R2's Morphine noted to be missing. Investigation initiated and remained ongoing. (Local Law Enforcement) has been notified. This incident report form includes a Timeline of events which documents that on 4/3/23 V4 (RN) reported there were missing bottles of residents' Morphine during the morning shift-to-shift narcotic count. This timeline documents that after a search of the medication cart, medication room, and the nurses' station the Morphine bottles were not found. This timeline documents that at 4:00p.m. on 4/3/23 facility nurses were given an in-service on narcotic medication pass and counting of narcotics. This form documents that local law enforcement was not notified of the potential diversion of residents' Morphine bottles until 4/6/23. This form also documents those two nurses were given a urine drug screen to determine presence of opioid narcotics on 4/3/23. On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated that once the allegation of missing Morphine was reported by V4 on 4/1/23, the remaining bottle of Morphine Sulfate oral solution belonging to R3 was pulled out of the medication cart. V2 stated that R1 and R2 had a total of three bottles that were missing and the only bottle that could be accounted for belonged to R3. V3 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she did not report this discrepancy to V1 as part of the diversion of narcotics investigation. On 4/19/23 at 9:00a.m. and 10:32a.m. V1 (Administrator) stated that on 4/3/23 V4 came in to work the day shift at 6:00a.m. after having last worked on 3/31/23. V1 stated that V4 noted on Monday 4/3/23 during the shift-to-shift narcotic count there was only 1 bottle of Morphine Sulfate left in the medication cart which belonged to R3. V1 stated that V4 refused to take over the medication cart on 4/3/23 because she had counted four bottles of Morphine Sulfate belonging to R1, R2 and R3 when she worked 3/31/23 and V4 knew that none of those residents would have used that much morphine over the weekend. V1 stated that after V4 alerted the facility there were narcotics not accounted for, V2 (Director of Nurses) proceeded to search through the medication carts, residents' rooms, and the nurses' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 5 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete station to find the missing medications. V1 stated there were five nurses who worked between 3/31/23 to 4/3/23 using that medication cart and all were interviewed. V1 stated that based on their interviews, two nurses who gave conflicting accounts of how many bottles of Morphine were in the narcotic drawer were suspected of having diverted the medication during their shifts 3/31/23 and 4/1/23. V1 stated that on the afternoon of 4/3/23 after an exhaustive search for the missing bottles of Morphine concentrate and after interviewing nursing staff, V1 formed a suspicion that the three missing bottles of Morphine were stolen or diverted. V1 verified that she did not immediately notify the State Agency or local law enforcement with her suspicions, but instead, notified both the State Agency and local law enforcement three days later on 4/6/23. On 4/24/23 at 12:40p.m. V1 stated that the original investigation of missing Morphine Sulfate bottles was for R1 and R2, but that she had been informed on 4/16/23 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated that she notified V11 (Sheriff's Deputy) and the State Agency on 4/16/23 after V2 informed her R3's Morphine bottle had doses missing that could not be accounted for. Event ID: Facility ID: 145726 If continuation sheet Page 6 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure an accurate reconciliation of controlled substances was performed during the shift-to-shift narcotic count which affected one of three residents (R3) reviewed for pharmacy procedures in a sample of five. Findings include: A Controlled Substance Storage policy dated 10/25/14 states, A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications. In addition, this policy states, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted, and Any discrepancy in controlled substance counts is reported to the director of nursing and pharmacy PIC immediately. The director of nursing documents irreconcilable discrepancies in a report to the administrator. A Facility Incident Report Form dated 4/19/23 documents,(State Agency) surveyor and DON (Director of Nurses/V2) noted that (R3) morphine count sheet to read 27ml (milliliters) and the bottle reads 24ml. Investigation initiated and is ongoing. (Local Law Enforcement) is here at present time and notified. On 4/19/23 at 2:50p.m. V2 (Director of Nurses/DON) stated the facility has an ongoing investigation into diversion of liquid Morphine Sulfate concentrate. V2 stated two residents (R1, R2) had bottles of Morphine bottles taken from the nurses' medication cart, but R3's partially used bottle of Morphine was not taken by the perpetrator. V2 stated that as an effort to prevent further misappropriation, V2 locked R3's Morphine in her office during the investigation. V2 proceeded to remove a partially used bottle of Morphine Sulfate 20mg (milligrams)/ml (milliliter) from the locked drawer in her office. V2 placed the bottle on her desk and noted that the bottle only contained approximately 24ml out of the 30ml originally in the bottle. V2 proceeded to note that on the controlled substance record for this bottle, there should be 27ml remaining. V2 stated she already knew as of 4/3/23 that nursing staff could not account for the discrepancy between the volume that should have been in R3's Morphine bottle and what was actually in the bottle. V2 stated she asked V4 (Registered Nurse/RN), the last person who signed out a dose of R3's Morphine, if she verified the amount left in the bottle during shift-to-shift narcotic count and at the time she dispensed the medication. V2 stated V4 told her she did not know when the volume/ number of remaining doses left in the bottle was last verified with the controlled substance record. R3's Controlled Substance Record which records doses remaining in R3's bottle of Morphine Sulfate liquid 20mg/ml dated as dispensed 3/20/23 documents that as of 4/4/23 V4 was the last to sign this document when V4 administered 0.25ml of Morphine (5mg) to R3 with a volume of 27ml recorded as still in the bottle. On 4/24/23 at 1:56p.m. V4 stated that she was the nurse who initially noticed there were bottles of Morphine Sulfate concentrate belonging to R1 and R2 missing from the medication cart on 4/3/23. V4 stated R3's bottle of Morphine was the only bottle that wasn't taken. V4 stated that during the investigation, it was discovered that there were fewer doses remaining in R3's bottle than what was recorded on the controlled substance record. V4 stated that nurses are supposed to put the bottles of liquid morphine on a flat surface to measure the remaining volume/doses in the bottles to properly reconcile the narcotics count. V4 stated that she and the other nurses had not been verifying the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 7 of 8 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 145726 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timber Point Healthcare Center 205 East Spring Street Camp Point, IL 62320 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 0755 quantity of Morphine left in each bottle but, instead, they were just verifying the number of bottles present. Level of Harm - Minimal harm or potential for actual harm On 4/24/23 at 12:40p.m. V1 stated that on 4/16/23 V2 notified V1 that R3's partially used bottle of Morphine was missing several doses. V1 stated that she compared R3's medication administration record (MAR) to R3's Morphine bottle controlled substance record/log and found that V8 had not signed out three doses of 0.25ml each. V1 stated that even after accounting for three doses, there was less Morphine in R3's bottle than what is accounted for in R3's medical record. V1 stated that after she talked with the nurses who reconcile the liquid Morphine bottles during the shift-to-shift narcotic count, she discovered that nurses were only counting the number of bottles and not the number of doses left in the bottles. V1 stated that the Morphine bottle has a clear narrow area on the side with measurements to determine how much liquid Morphine remains in the bottle. V1 stated the bottles must be placed on a flat surface to make an accurate determination of the number of doses left. V1 stated that on the controlled substance record nurses were just writing the doses they gave but still not ensuring the correct volume was in the bottle. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 8 of 8