Inspection·February 20, 2024

F 0686 R1's discharge to the hospital nor of a physician ordered treatment. Level of Harm - Minimal harm or potential for actual harm On 2/14/24 at 10:24 a.m., R1 had a silicone border foam dressing in place and a packing in the wound. V3 (Wound Nurse) removed the packing. R1 had an open area with depth, and the base of the wound was 100% covered with yellow slough therefore it was unable to be determined the depth. V3 stated that R1's wound was currently unstageable with the base being covered with slough. Residents Affected - Few On 2/20/24 at 9:40 a.m., V5 (Nurse Practitioner) stated that when she saw (R1) on 1/11/24 she did not have a Stage 2 pressure ulcer on her coccyx, but she did have one present on admission to the hospital on 1/17/24. If there was a (silicone border foam dressing) on her coccyx then there should have been a treatment order and I should have been notified. I was not notified that she had a Stage 2 pressure ulcer on her coccyx until she was readmitted on [DATE]. 2. R3's (Admission) Body Map, dated 2/8/24, documents that R3 has an unstageable pressure ulcer to her right lower buttock that measures 6 cm (centimeters) x 4 cm as well as an area to the coccyx/sacral area that measures 4 cm x 4 cm x 1.5 cm. R3's Physician's orders, dated 1/14/24-2/14/24, document that R3 was admitted with a physician ordered treatment for R3's pressure ulcer on her coccyx. R3's physicians orders have no documentation of a physician ordered treatment for R3's pressure ulcer to her right lower buttock. On 2/14/24 at 10:04 am, V3 (Wound Nurse) removed a heart shaped silicone border foam dressing from R3's coccyx area. R3 had an open area with depth to her coccyx, R3 also had an irregular shaped wound to her right lower buttock that was covered with slough (gray black tissue). The right lower buttock wound was partially covered by the silicone border foam dressing edges. On 2/14/24 at 10:14 a.m., V3 confirmed there was no physician ordered treatment in place for R3's right lower buttock pressure ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 2 of 4 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 02/20/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to ensure a resident's pain was controlled, and assess pain on a daily basis for one of one reviewed for pain in the sample of three. These failures resulted in R2 having excruciating pain during wound care. Residents Affected - Few Findings include: The facility's Pain-Clinical Protocol, dated 2008, documents, The staff will discuss significant changes in levels of comfort with the attending physician who will adjust interventions accordingly. This may include adjustments of regular and PRN (as needed) analgesic doses to find the best combination of effectiveness and tolerable side effects, or possible addition of non-pharmacological interventions. R2's Care plan, dated 11/14/23, documents, R2 has increased potential for complications and discomfort related to the diagnosis of arthritis. The care plan also documents the following interventions: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors; Monitor and record any non-verbal signs of pain: (e.g. guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.); Use pain relief measures: (distraction, imagery, relaxation, etc.) Evaluate/record/report effectiveness. R2's Physician's orders, dated 1/14-2/14/24, document that R2 has the following pain medication orders: oxycodone-acetaminophen 7.5-325 mg one tablet every six hours; ibuprofen 400 mg one tablet every eight hours; Tylenol 325 mg two tablets every four hours as needed for pain. R2's Pain Observation, dated 2/7/24, documents that R2 states that she has almost constant pain. R2's MAR (Medication Administration Record), dated 2/1-2/15/24, has no documentation of R2's pain being assessed on a daily basis with the administration of pain medication. On 2/13/24 at 11:13 a.m., R2 was alert leaning forward in her wheelchair. R2 stated I have two pressure ulcers on my backside. I have a really big area on my right calf. It is from a stocking thing that was way to tight and I told that CNA (Certified Nurse Aide) to not put it on. They tell me I need to lay down more, but I hate to use the (full mechanical lift) more than I need to I don't like that thing. It hurts so bad when they get me up and down. I've got a bad hip that if they move that leg it's instant awful pain. The hip needs replaced, but they won't do surgery on me. I absolutely dread when they change my dressings. The one on my leg is awful. It burns so bad when they do it. I swear every single time I cry. The one on my backside hurts when they do it as well. I feel like I'm going to cry, but I'm able to hold that one in normally. I just pray they would heal up so I wouldn't have to go through that pain. On 2/14/24 at 9:10 am,, R2 was alert lying in bed. R2 asked V3 (wound nurse) if V3 could do her buttocks wound dressing changes before doing her legs since it was so painful for the dressing changes on her legs. V2 (Director of Nursing) was also present during R2's wound care. R2 stated, I'm sorry I'm going to yell out and probably cry because these hurt so bad. V3 removed a silicone border foam dressing from R2's coccyx and R2's left ischium. V3 cleansed both wounds with normal saline. During the cleansing, R2 was grimacing. R2's coccyx wound was a open area with depth. The base of R2's coccyx pressure ulcer was 75% covered yellow gray tissue (slough). So it is undetermined as to how deep the actual wound is. V3 began to pack the coccyx wound, and R2 began to cry out, Ow (Ouch) it hurts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 3 of 4 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 02/20/2024 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 0697 Level of Harm - Actual harm Residents Affected - Few Please stop. Ow!. V3 replied with I'm sorry, and continued performing wound care. R2 continued to cry out until V3 covered the wound with a silicone border foam dressing. R2 also had an open area with depth to R2's left ischium. As V3 began packing that area, R2 started crying out in pain again until the wound was covered with the silicone border foam dressing. Then, V3 began to remove the gauze roll from R2's right leg, and R2 began to cry stating, I don't like this one it burns so bad! V3 proceeded to removed the dressing covering R2's right calf. R2 began to bite her blanket to muffle her crying out as tears were coming out of her eyes. She began to scream, Ow! What are you doing? Don't! Please stop it's burning so bad! R2's entire back of her right calf was a large open/raw area. V3 began to cleanse the wound with normal saline and R2 began yelling out again for V3 to stop because it was burning so bad. V3 covered the wound with (Sodium Chloride impregnated gauze dressing)and and ABD (abdominal) pad. Then, she covered it all with a gauze roll while R2 continued to cry out. After the treatment was completed R2 kept repeating, I'm so sorry I was crying and yelling those dressing changes just hurt so bad! On 2/15/24 at 9:40 a.m., V3 stated that prior to wound care, R2 had pain medication at 6:00 a.m. when she received Ibuprofen 400 mg and oxycodone-acetaminophen 7.5 -325 mg (milligrams). On 2/20/24 at 10:52 a.m., V4 (Registered Nurse) stated, (R2) has a lot of pain, especially in her hips and her legs. She cries out a lot still. She cries if we turn her, roll her, or even if someone bumps her wheelchair. When we do her dressing changes she complains a lot about the burning in her right calf. She will keep repeating, 'It burns. It burns.' She normally gets her scheduled oxycodone at 6:00 a.m., and then we do her dressing changes between 6:30-7:00 a.m. Even when we give it at that time she still complains about the wound care and positioning during it as well. She has a horribly bad hip. It hurts her more to lay down then be up in her wheelchair. On 2/20/24 at 10:45 a.m., V6 CNA stated that (R3) cries out in pain when they transfer her in the (full mechanical lift). She complains about her legs hurting her. She complains that her right calf burns and is painful pretty frequently. On 2/20/24 at 9:40 a.m., V5 (Nurse Practitioner) stated, I'm not aware that (R2) doesn't lay down because of it hurting during the transfer. She has a hip that she needs replaced, but the surgeons are not wanting to replace it, and it causes her pain with movement. I know that she struggles with pain during the dressing changes, especially her right calf dressing change. If her pain isn't under control with the oxycodone, I'm going to have to try something different. On 2/20/24 at 11:10 a.m., V2 stated, (R2) did cry out quite a bit during the dressing change last Thursday (2/15/24). I've never heard her cry out like that before, but we continued to do the wound care. She had her scheduled pain medication that morning, but she doesn't have anything PRN. The scheduled pain medication should cover her. She complains of the right calf wound burning with the dressing change. If someone complains of pain during a dressing change I just try to get it done faster so the pain will stop sooner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 4 of 4