Health inspection·March 13, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN). ` R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The facility should not be letting their residents run out of medications. I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until a day after (R2) already ran out of his Oxycodone. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 2 of 14 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 03/13/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on record review and interview the facility failed to ensure the residents' representatives were invited and attended care plan conferences for two of three residents (R1 and R3) reviewed for care planning in the sample of three. Findings include: The facility's Care Planning-Interdisciplinary Team policy dated 08/06 documents, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. 1. R1's Medical Record dated 8-24-23 through 3-8-24 does not include any documentation of V8 (R1's Power of Attorney/POA) being invited or attending R1's care plan meetings except on one occasion (2-14-24). On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, I have not been invited to a care plan meeting since (R1) was admitted until 2-14-24. I need to be involved with (R1's) care plan meetings to ensure the facility is taking appropriate care of (R1). 2. R3's Medical Record dated 3-1-23 through 3-8-24 does not include documentation of R3's Power of Attorney/POA (V12) being invited or attending R3's care plan meetings. On 3-8-24 at 12:55 PM R3 stated, I do not think (V12) comes to my meetings. I would like for (V12) to be able to. On 3-8-24 at 2:00 PM V10 (MDS/Minimum Data Set Coordinator) stated, The facility does not have a care plan coordinator right now. I cannot find any documentation of (V8) or (V12) being invited to (R1's) and (R3's) care plan meetings, except for the one meeting (V8) attended on 2-14-24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 3 of 14 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 03/13/2024 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 - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform a pain assessment while the residents were not receiving their prescribed opioid medications, and failed to develop a pain plan of care for two of three residents (R1 and R2) reviewed for pain in the sample of three. These findings resulted in R1, who suffers from bone cancer, experiencing uncontrolled lower back pain and resulted in R2, who suffers from Osteomyelitis from a flesh-eating wound caused by a spider bite, experiencing uncontrolled severe continuous and unbearable pain to his right lower leg wound. Residents Affected - Few These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Pain Management policy dated 07/2019 documents, Policy: It is the policy of the facility to facilitate resident safety, independence, promote resident comfort, preserve and enhance resident dignity and facilitate life involvement. The purpose of this policy is to accomplish the goals through an effective pain management program. The resident's descriptive words regarding the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in pain. Pain assessment protocol may be initiated under any of the following situations: Resident received routine pain medication and/or pain is not controlled and a change in pain identification related to behavior, cognition, or mood. An immediate care plan will be initiated at the time of admission for any resident with physician orders for pain management, when the resident expresses pain, or exhibits behaviors indicative of having pain. An interdisciplinary process and care plan will be developed and implemented based on the assessed findings, pain rating scale, and pain-relieving strategies (interventions). A provision of pain treatment that includes pharmacological and non-pharmacological interventions will be included in the care plan. Responsible use of opioid's medications will include the monitoring of the use of opioids. The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Rapid discontinuation can result in uncontrolled pain. R1's History and Physical dated 8-10-23 documents, Chief complaint is intractable back pain. Multiple Myeloma. (R1) has known Multiple Myeloma has been under therapy by Oncology. (R1's) pain has become severe. (R1) cannot ambulate. Pains all up and down (R1's) spine. (R1) apparently has lesions at various levels of the spine with her myeloma. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain. R1's admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours. Morning time is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 4 of 14 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 03/13/2024 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 - Immediate jeopardy to resident health or safety Residents Affected - Few a hard time of day regarding pain. (R1) is able to sleep at night. Location (of pain) is mid-back today. Planning to increase fentanyl patch (dose). R1's Care Plan dated 8-23-23 (Admission) through 3-7-24 does not include a plan of care to address R1's chronic pain due to Multiple Myeloma. R1's Progress Notes dated 10-4-24 and signed by V4 (R1's Palliative Physician) document, (R1) is being seen in the geriatric clinic today for palliative care follow-up regarding pain management associated with Multiple Myeloma. R1's Progress Notes dated 10-5-24 and signed by V6 (RN/Registered Nurse) document, (R1) seen by (V4/R1's Palliative Care Physician) with Fentanyl patch increased to 100 mcg per hour for diagnosis of cancer pain. Follow-up with (V4) in four months. Will continue to monitor. R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission. R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24. The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. This is becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals. R1's Progress Notes dated 2-21-24 and signed by V4 (R1's Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain. R1's Medical Record does not include a completion of a pain assessment after R1 did not receive her scheduled Fentanyl patch from 1-25-24 through 2-6-24. On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back. On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated R1 went without her scheduled Fentanyl Patch for from 1-25-24 through 2-6-24. V2 also stated R1's Fentanyl Patch was given for R1's pain related to bone cancer. V2 confirmed R1 did not have a pain assessment conducted after missing her Fentanyl Patch dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 5 of 14 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 03/13/2024 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 - Immediate jeopardy to resident health or safety On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective. Residents Affected - Few On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her. On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (R1) was going crazy and was in such pain while being out of her Fentanyl. It was just awful. (R1) has terrible bone pain and cancer. On 3-8-24 at 4:25 PM V10 (MDS/Minimum Data Set Coordinator) stated, (R1) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R1) did not have a pain care plan. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg. R2's MDS assessment dated [DATE] documents R2 is cognitively intact and has frequent pain at a pain intensity of 7 on a 0-10 pain scale (zero being no pain and ten as the worst pain you can imagine). R2's Pain Observation assessment dated [DATE] documents R2 had almost constant moderate pain at a 7 and received scheduled and as needed pain medications for pain control. R2's Progress Notes dated 1-8-24 and signed by V7 (Nurse Practitioner) document, (R2) requested to see me due to pain not currently controlled with Oxycodone 10 mg every four hours PRN (as needed). New orders: Schedule Oxycodone 10 mg tablets three times daily and continue with current Oxycodone 10 mg one tablet every four hours as needed. R2's Care Plan dated 8-16-23 (Admission) through 3-7-24 does not include a plan of care to address R2's chronic pain due to Osteomyelitis and wound to the right lower leg. R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN).` R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 6 of 14 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 03/13/2024 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 - Immediate jeopardy to resident health or safety R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals. R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. (R2) went all weekend and today without pain medication. Residents Affected - Few R2's Medical Record does not include a completion of a pain assessment after R2 did not receive his scheduled Oxycodone on 1-26-24 through 1-28-24. On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and unbearable. It felt like my wound was split open and burning. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) has Osteomyelitis (bone infection) and has had several debridements done and has a lot of pain with this wound. I am sure his pain was excruciating when he had to go without his Oxycodone. On 3-8-24 at 9:45 AM V2 (DON) confirmed that R2 did not have a pain assessment completed after missing his scheduled doses of Oxycodone on 1-26-24 through 1-29-24. On 3-8-24 at 4:25 PM V10 (MDS Coordinator) stated, (R2) did not have a pain plan of care developed prior to today. I am responsible for developing pain care plans. I do not have a reason as to why (R2) did not have a pain plan of care. The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not administered to treat R1's excruciating bone cancer pain. V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM. On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-13-24 R1's opioid pain medications were available and being administered. On 3-11-24 R1 was assessed and re-evaluated by V10 (MDS/Minimum Data Set Coordinator) for adequate pain control and pain levels that were tolerable, and V10 updated R1's care plan to include pain relieving interventions/medications. 2. On 3-13-24 R2's opioid pain medications were available and being administered. On 3-11-24 R2 was assessed and re-evaluated by V10 for adequate pain control and pain levels that were tolerable, and V10 updated R2's care plan to include pain relieving interventions/medications. 3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 7 of 14 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 03/13/2024 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 4. On 3-11-24 V1, V2, and V10 assessed and re-evaluated all residents for adequate pain control and pain levels that were tolerable. Level of Harm - Immediate jeopardy to resident health or safety 5. On 3-11-24 V1 and V2 ensured all residents had tolerable pain levels. Residents Affected - Few 6. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on the facility's Pain Clinical policy and procedure, performing pain assessments with changes in pain management or an increase in pain, and the facility's Pain Management policy. 7. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on developing pain care plans and implementing pain relieving interventions. 9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pain control concerns. 10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all Pain policies and procedures and concerns with pain control. Date of Completion: 3/11/2024 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 8 of 14 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 03/13/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain scheduled opioid medications from the pharmacy for two of three residents (R1 and R2) reviewed for pharmacy services in the sample of three. This failure resulted in R1 abruptly stopping and missing her scheduled Fentanyl patch (Opioid Medication) for two weeks resulting in R1 experiencing withdrawal symptoms of a fall, night terrors, drooped eyes with continuous blinking, shallow and quick breaths, non-reactive pupils, garbled speech, and hypertensive. This failure also resulted in R2 abruptly stopping his scheduled Oxycodone (Opioid Medications) for three days resulting in R2 experiencing withdrawal symptoms of refusing to eat, chills, nausea, and vomiting. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3-11-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility Pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy dated 10-25-14 documents, Facility staff monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 1. A clinical significant change in condition/status. a. An unexplained decline in function or cognition. b. A worsening of an existing problem or condition. c. A new or worsening psychiatric manifestation or distressed behavior. d. Acute onset of signs or symptoms or worsening of a chronic problem. Medication error. G. The attending physician is notified promptly of any significant error or adverse consequence. J. The following information is documented in an incident report and in the resident's clinical record: Factual description of the error or adverse consequence. Name of physician and time notified. Physician's subsequent orders. Resident's condition for 24 to 72 hours or as directed. The United States Food and Drug Administration Safety Communication Website article dated 4-9-19 documents, Opioid's are a class of powerful prescription medicines that are used to manage pain when other treatments and medicines cannot be taken or are not able to provide enough pain relief. Patients taking opioid pain medicines long-term should not suddenly stop taking your medicines without first discussing with hour health care professional a plan for how to slowly decrease the dose of the opioid and continue to manage your pain. Even when the opioid dose is decreased gradually, you may experience symptoms of withdrawal. Rapid discontinuation can result in uncontrolled pain or withdrawal symptoms. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide. R1's Face Sheet documents R1 is an [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Multiple Myeloma not having achieved remission and low back pain. R1's admission Orders dated 8-23-24 document R1 was admitted to the facility on Fentanyl (Opioid) 75 mcg (microgram)/hour transdermal extended release one all up patch every 72 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 9 of 14 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 03/13/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few R1's Care Plan dated 9-29-23 documents, (R1) is at risk for falling related to her recent hospital stay for COPD (Chronic Obstructive Pulmonary Disease), cancer with chemotherapy treatments, and generalized weakness. Approach: 1-29-24 (R1) will be schedules to see her physician for night terrors. R1's Physician's Orders dated 10-5-24 through 3-8-24 document, Fentanyl 100 mcg per hour one patch transdermal once a day every three days at 9:00 PM for the diagnoses of Multiple Myeloma not having achieved remission. R1's Medication Flow Sheets dated 1-1-24 through 2-31-24 document R1's Fentanyl Patch 100 mcg/hour transdermal placed at 9:00 PM was not administered as scheduled on 1-25-24, 1-28-24, 1-31-24, or 2-3-24. These same Medication Flow Sheets document R1 did not have a Fentanyl 100 mcg/hour patch applied until 2-6-24. R1's Clinical Record does not include documentation, as directed by the facility pharmacy's Preventing and Detecting Adverse Consequences and Medication Errors policy. of physician notification or a factual description of why R1 did not receive her scheduled Fentanyl Patch from 1-25-24 through 2-6-24, or R1's condition while missing the scheduled dose of her Fentanyl Patch from 1-25-24 through 2-6-24. R1's Progress Notes dated 1-29-24 at 5:49 AM and signed by V5 (RN/Registered Nurse) document, At 5:45 am (R1) heard yelling (female's name) and had fallen in room. Fall was witnessed by roommate who states (R1) was having a nightmare and got out of bed unaware. (R1) was observed trying to stand herself up when this nurse entered the room. (R1) states she hit her knees a bit and her back. (R1) states this is a normal occurrence for her, and she needs to see someone about the night terrors. No other noticed injuries other than some bruising starting to bilateral knees. R1's Medication Error Report signed by V1 (Administrator) and V2 (Director of Nursing) on 1-31-24 documents, Medication as ordered: Fentanyl 100 mcg (micrograms)/hour patch. Description of error: Medication unavailable/no refills. Date of error: 1-25-24, 1-28-24, and 1-31-24. Reason for error: Pharmacy error. Corrective action taken: Working with pharmacy and physician to get resolution. Measures taken to prevent recurrence (this section is incomplete). R1's Progress Notes dated 2-3-25 at 12:57 AM and signed by V5 (RN) document, This nurse was called into resident's room by the CNA (Certified Nursing Assistant) asking me to lay eyes on (R1). (R1) at this time was having a night terror. Upon assessment, (R1) was noted to have drooped eyes with continuous blinking, shallow, quick breaths, non-reactive pupils, and hypertensive. (R1) was responding appropriately to some questions but speech was also garbled and hard to comprehend. This nurse asked another nurse to also lay eyes and 911 was called at 4:32 AM. Shortly after, (R1) became more responsive and appeared to just be having a night terror that she had not fully come out of. EMS arrived at 4:35 AM and evaluated and was determined to be stable. The facility's email dated 2-5-24 and sent to the facility's pharmacy from V2 (Director of Nursing) states, I am not sure how things need to be fixed, but (R1) has been without her Fentanyl patch going on two weeks which is completely unacceptable. Last week I spoke with pharmacy, and they stated that they needed a renewal script signed and sent over by the doctor of which was done on 1-29-24. Today I find out that these patches still have not been sent and my nurse was told my pharmacy that there was no dosage attached to the ordered. I was not notified of this nor was the doctor notified of anything. (V7/Nurse Practitioner) pulled the order that she personally send last week and the correct dosage that you can see in the forwarded message. The dosage is clearly attached. This is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 10 of 14 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 03/13/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few becoming a huge problem of people going days without their narcotics and is causing residents to being in a great deal of pain or even worse going into withdrawals. There needs to be something figures out or communications sent from the pharmacy to me as well as the prescriber for narcotics needing new scripts signed/renewed so that I can follow-up before the resident runs out of the medication. R1's Physician's Progress Notes dated 2-21-24 and signed by V4 (R1's Palliative Care Physician) document, A few weeks ago (R1) was having significant issues with delirium at night and there was a night where an ambulance had to be called. On further investigation from family, turns out (R1) had not been getting her fentanyl patches. There was a list of excuses that the nursing home provided, though (V2/Director of Nursing) never did get back to the family about why the patches had no bed obtained from pharmacy or why physician involvement was no pursed in order to get the right order. The nursing home did not send a med (medication) list with (R1) so we will work on getting one. About four to six weeks ago (R1) went through opioid withdrawal because the facility did not have (R1's) fentanyl patches. I am unsure about what efforts (if any) the facility pursued to get (R1) her pain medications. Not only was my office unavailable during this time, the patient's primary care provider's office was available and our nurse practitioner who rounds at the facility would have also been available to help troubleshoot. This appears to be inadequate care and my duty as a mandatory reporter required me to report this. Assessment and recommendations: 1. Encounter for palliative care. 2. Multiple Myeloma not having achieved remission. 3. Bone Metastasis. 4. Cancer related pain. 5. Drug-induced constipation. 5. Opioid withdraw delirium resolved. On 3-8-24 at 9:30 AM R1 was lying in bed in her room. R1 stated, I did not know I wasn't getting my pain medication. I know my lower back was on fire. Most all of my pain is in my lower back. I fell and was not feeling very well a few weeks ago. On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, I was informed on 1-25-24 that (R1's) Fentanyl patch was not delivered by pharmacy, and we needed a renewal slip from the physician. On 1-30-24 I was told (R1) still did not have her Fentanyl delivered by pharmacy. I called pharmacy and they said the script (V7/Nurse Practitioner) sent on 1-29-24 did not include the amount. I looked at the script and it did include the amount. I called the pharmacy again on 1-31-24 and (R1) still had not received the Fentanyl patch and said they still did not have a physician script. On 2-5-24 I was told (R1's) Fentanyl was still not delivered by pharmacy. I sent an email on 2-5-24 and told them it us unacceptable for (R1) to have to go two weeks without her Fentanyl. Finally, the pharmacy delivered it that night. I did not know (V4/R1's Palliative Care Physician) was the physician prescribing (R1's) Fentanyl. The facility switched pharmacies on 1-1-24 and pharmacy has communication issues. On 3-8-24 at 11:00 AM V4 (R1's Palliative Care Physician) stated, I am responsible for (R1's) Palliative care. I saw (R1) in my office on 2-21-24. I was told on 2-21-24 that (R1) did not receive her Fentanyl patch for two weeks and was experiencing withdrawals. I was not informed by the nursing home of (R1's) Fentanyl patch not being available or administered. It is very dangerous to abruptly stop Fentanyl. (R1's) experiencing night terrors, garbled speech, shallow respirations, and falls would have definitely been withdrawal symptoms from abruptly stopping her Fentanyl. When the pharmacy was not sending the Fentanyl I should have been contacted. The facility should have been doing everything in their power to get the Fentanyl and should have been following up with me and pharmacy daily. (R1) should not have gone two weeks without Fentanyl. Fentanyl is the only medication that keeps (R1's) pain control. (R1) has excruciating pain from bone cancer and I have had to increase (R1's) Fentanyl dose to keep the pain under control. No other pain medication has been effective. On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The pharmacy the facility started using a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 11 of 14 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 03/13/2024 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 0755 Level of Harm - Immediate jeopardy to resident health or safety pharmacy January 1, 2024, and this pharmacy has not been good. I did not know (R1) had went without Fentanyl for two weeks. (R1) should not have never been without her Fentanyl, especially for two weeks. I was only notified one day (1-19-24) of the need for a signed prescription. (R1) has bone cancer to her spine and her pain is very detrimental to her. The facility should have been notifying a physician and pharmacy daily to get (R1's) Fentanyl in before it ran out or used an alternate pharmacy to get the medication. The facility should not be letting their residents run out of medications. Residents Affected - Few On 3-8-24 at 12:25 PM V8 (R1's Power of Attorney) stated, (R1) told me that she fell out of bed because she had nightmares. (R1) said 911 was called and came to see her. On 2-1-24 I called the nurse (V9/RN), and she told me (R1) had been out of her Fentanyl patch for two weeks and that was causing her night terrors. (V9) told me 911 had a hard time waking her up and thought she was having seizure like activity. I called (V2) on a Monday (2-5-24) and told (V2) that (R1) was out of her pain patch and (V2) told me she was not out of the pain patch and was not aware of (R1) being out of the pain patch. I did not hear back from (V2), so I called back on a Wednesday (2-7-24) and spoke to (V2). (V2) did say (R1) fell out of bed once and had been out of her Fentanyl patch for two weeks. (V2) said (V7) tried to send the prescription in to pharmacy, but the facility still did not receive the prescription. I was never notified of (R1) falling out of bed or being out of Fentanyl or 911 being called. (V2) told me the pharmacy got the Fentanyl on 2-8-24. On 3-8-24 at 1:00 PM V9 (RN/Registered Nurse) stated, (R1) did not have her Fentanyl patch for two weeks and was having withdrawals and night terrors. 2. R2's Face Sheet documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Type II Diabetes Mellitus and a non-pressure chronic ulcer of unspecified part of right lower leg. R2's Physician's Order Report date 3-1-24 through 3-8-24 documents, Order date 1-8-24 to current: Oxycodone 10 mg (milligram) tablet two tablets three times daily. Order date 11-30-23 to current: Oxycodone 10 mg one tablet every four hours as needed (PRN). ` R2's Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2's Oxycodone 10 mg two tablets was not administered as ordered on 1-26-24 at 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, 1-27-24 at 8:00 AM, 2:00 PM, or 8:00 PM, and 1-28-24 at 8:00 AM. These same Medication Flow Sheets dated 1-1-24 through 1-31-24 document R2 did not receive a PRN dose of Oxycodone 10 mg on 1-26-24 through 1-31-24. R2's Progress Notes dated 1-28-24 at 3:11 PM and signed by V9 (RN) documents R2 was complaining of increased pain and withdrawals due to his scheduled pain medication not being available from pharmacy due to insurance. This same not documents R2 remained in bed and was not eating meals. R2's Progress Notes dated 1-29-24 at 1:47 PM and signed by V11 (RN) documents, (R2) has remained in bed thus far today. Withdrawal symptoms present due to new script needing written for Oxycodone. (R2) went all weekend and today without pain medication. Complained of chills, feeling hot, nausea, vomiting, and overall feeling sick. (R2) refused both breakfast and lunch. On 3-8-24 at 11:10 AM R2 was lying in bed. R2's right lower leg was wrapped in gauze. R2 stated, I was out of the Oxycodone for three days. I was bit by a [NAME] Recluse spider and that is why I am here for treatment. When I was out of the Oxycodone, I was having withdrawals of nausea, vomiting, and dry heaving and I was having pain at an 11 on a 1-10 pain scale. The pain was continuous and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 12 of 14 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 03/13/2024 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 0755 unbearable. It felt like my wound was split open and burning. Level of Harm - Immediate jeopardy to resident health or safety On 3-8-24 at 9:45 AM V2 (Director of Nursing/DON) stated, (R2) had to go without his Oxycodone for three days because the pharmacy said they did not receive his prior authorization. (R2) experienced withdrawal symptoms. Residents Affected - Few On 3-8-24 at 11:40 AM V7 (Nurse Practitioner) stated, The facility should not be letting their residents run out of medications. I oversee (R2's) care at the facility. (R2) ran out of Oxycodone on 1-26-24. I was not notified of the need for a prior authorization until (R2) already ran out. (R2) did not get his medication for three days until I called (V2) and told her the facility needs to pay for the medication until (R2's) prior authorization gets sent. (R2) got bitten by a [NAME] Recluse spider that caused a wound with bone exposure. (R2) was having withdrawals and should not have gone without his Oxycodone. The Immediate Jeopardy started on 1-25-24 at 9:00 PM when R1's scheduled Fentanyl patch 100 mcg/hour was not delivered by pharmacy to treat R1's bone cancer pain, causing R1 to experience opioid withdrawals symptoms. V1 (Administrator) and V2 (DON) were notified of the Immediate Jeopardy on 3-11-24 at 9:36 AM. On 3-13-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3-13-24 R1's opioid pain medications were available and being administered. 2. On 3-13-24 R2's opioid pain medications were available and being administered. 3. On 3-13-24 all residents who currently had orders for opioid pain medications had their pain medications available and were being administered. 4. On 3-11-24 V1 and V2 reviewed the facility's Controlled Substance Prescriptions Policy to ensure the policy included ordering and receiving controlled medications to ensure that all controlled (opioids) are filled immediately. 5. On 3-11-24 V1 and V2 in-serviced all facility nurses and department heads on notifying V1 and V2 immediately when opioid medication is not delivered by the pharmacy and V2's responsibility of contacting the pharmacy and taking action to ensure the medication is available and /or administered as ordered by the physician. 6. Pharmacy has been sending a controlled substance requiring prescription report daily to V1's and V2's email since 3-11-24 and this report has been reviewed daily by V1 and V2. 7. On 3-11-24 V2 in-serviced all facility nurses and department heads on notifying the attending physician, and /or nurse practitioner, V2, and V1 when a medication is not administered as ordered by the physician, ensuring all residents medications are obtained prior to the medications running out, and ordering and faxing medication refills to the pharmacy. 8. On 3-11-24 V13 (Medical Director) pharmacy staff were in-serviced by V1 and V2 regarding the facility's Controlled Substance Prescription Policy to ensure Opioid medications are filled and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 13 of 14 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 03/13/2024 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 0755 delivered to the facility immediately. Level of Harm - Immediate jeopardy to resident health or safety 9. On 3-11-24 V13 (Medical Director) made aware of the Immediate Jeopardy regarding pharmacy concerns and opioid medications not being available for administration. Residents Affected - Few 10. On 3-11-24 the facility conducted an emergency QA (Quality Assurance) meeting regarding all of the new pharmacy policies and procedures. 13. On 3-13-24 the pharmacy conducted an in-service with all nurses regarding medication pass guidelines for controlled substances. Date of Completion: 3/11/2024 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 14 of 14