Inspection·July 11, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review the facility failed to provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 70 resident's residing in the facility. Residents Affected - Many Findings include: R43's medical record documents that R43 was transferred to a local hospital on 3/15/24. No evidence of a facility notification to R43 of a transfer/discharge was present in R43's chart. R56's medical record documents that R56 was transferred to a local hospital on 6/4/24. No evidence of a facility notification to R56 of a transfer/discharge was present in R56's chart. On 7/8/24 at 1:15 PM V2/DON verified the facility did not provide R43, R56, or their representatives with a written notice of transfer. V2/DON stated, I am not aware of a written notice of transfer form we (the facility) are supposed to give to the residents when they discharge to the Hospital. We (the facility) only send the continuity of care form that has the resident's current vitals and medications. The nurses would be the ones to give the resident the written notice of transfer, but they are not aware of that form and have not been giving it to any resident as I am just now finding out about it. On 7/10/24 at 8:42 AM V4/Social Service Director stated, I do not give a resident or their representative a copy of a written notice of transfer. I am not even aware of that form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 2 of 12 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 07/11/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a personalized Care Plan for 1 resident (R67) of 24 residents reviewed for personalized Care Plans in the sample of 34. Findings Include: The Care Planning policy dated August 2006, documents Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. R67's current computerized medical record, documents R67 was admitted to the facility on [DATE] with a diagnosis of Venous Insufficiency (Chronic) (Peripheral), Sciatica, Left Side (Primary), Major Depressive Disorder, Anxiety Disorder, Hypertensive Heart Disease Without Heart Failure, and Localized Edema. R67's MDS (Minimum Data Set) dated 6/10/24 documents a BIMS (Brief Interview for Mental Status) Score of 13/15, indicating cognition intact. On 07/08/24 at 10:47 AM, R67 was sitting in her room in her wheelchair. R67 stated her legs have been swelling a lot and R67 needs to wear compression stockings daily. R67's Physician Orders dated 6/4/24 documents that R67 is to wear (vascular compression stockings) from 6:00 AM to 6:00 PM daily. R67's Care Plan does not document that R67 should wear compression stockings. On 7/9/24 at 2:07 PM, V2/Director of Nursing stated there is not a Care Plan for R67 wearing Compression Hose. On 7/10/24 at 12:36 PM, V3/Assistant Director of Nursing/Wound Nurse stated (R67) has Venous Insufficiency and has an order to wear compression stockings. There was no Care Plan for R67's compression stockings so I added it today that (R67) needs to have them on daily from 6:00 AM to 6:00 PM. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 3 of 12 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 07/11/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on Observation, Interview and Record Review, the facility failed to provide physician ordered Ketoconazole cream (anti-fungal topical cream) timely to a resident with known topical yeast growth for one of one resident (R38) reviewed for skin conditions in the sample of 34. Residents Affected - Few Findings include: The facility's Drug Order Policy (undated), documents It is the policy of this facility to obtain a physician's order for all medications and treatments and to process medication orders to ensure the resident's medical plan of care is implemented, on a timely basis. This same policy documents All orders from a licensed practitioner for resident drugs are processed by a licensed nurse and entered in the resident's medical record. The medication orders are processed timely, i.e. (that is) called/faxed to the selected pharmacy, is indicated on the resident identification. Drug order shall be transcribed onto the medication record by the licensed nurse who received them as soon as practical after the physician's order is received. R38's current care plan, dated 6/26/24, documents (R38) is at risk for pressure ulcers and other alteration to skin integrity due to Diabetes Mellitus, Heart Failure, Weakness, Obesity and COPD (Chronic Obstructive Pulmonary Disease). (R38) was admitted to the facility with a pressure ulcer to the coccyx area and a growth by the right side of groin. Areas are healed. This care plan lists interventions Treatments will be done as ordered. On 7/9/24 at 9:45 AM, R38 was in his room lying in bed. R38 stated They (the facility) are not processing or completing orders like they're supposed to. I had an order for a fungal cream starting on 6/11/24. I never got it, and no one could tell me why or where it was. They just didn't have it. I went back to the doctor a while later and told them and then the doctor's office ordered it again. R38 stated he has had his leg removed and he gets yeast growth in skin fold areas on his body which is why the doctor ordered an anti-fungal cream. R38's nursing progress note, dated 6/11/24 at 2:43 PM, documents (R38) returned from an appointment with (V9, R38's Primary Physician) to start Ketoconazole. No percentage written or where to apply, or dosage. Will fax office to ask. R38's electronic medical record does not document any further clarification on the Ketoconazole order until 6/28/24 (17 days after the medication was originally ordered to be initiated). R38's nursing progress note, dated 6/28/24 at 10:43 AM, documents (V9) was following up with a cream that was ordered. They (V9's office) had sent the script (prescription) to our pharmacy. This nurse will place order for (Ketoconazole) cream as (V9) ordered. On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/Infection Control Preventionist) stated (R38) does get Ketoconazole cream to his groin area because he has a history of a growth there and gets yeast areas in his groin folds. If there are paper orders or faxes from physician's office, they should get added to the computer by the nurse and then they are scanned into the resident's record. On 7/10/24 at 3:15 PM, V2 (Director of Nursing) confirmed there was a delay in the Ketoconazole cream being started for R38 and stated she wasn't exactly sure why there was confusion or delay with starting it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 4 of 12 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 07/11/2024 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide physician ordered yogurt with all meals, obtain physician ordered daily weights, provide lunch meals when out of the facility at scheduled hemodialysis, communicate with the dialysis center before and after treatments, monitor a central venous catheter dialysis port and ensure a resident's care plan documents detailed dialysis care and required services for a resident receiving renal hemodialysis for one of one resident (R38) reviewed for dialysis in the sample of 34. Residents Affected - Few Findings include: The facility's Dialysis Transfer Agreement, dated 7/19/10, documents Facility shall ensure that all appropriate medical, social, administrative and other information accompany all designated residents at the time of transfer to (dialysis) Center. This information shall include, but is not limited to, where appropriate, the following: Appropriate medical records, including history of the designated resident's illness, including laboratory and x-ray findings; Treatment presently being provided to the designated resident, including medications and any changes in a patient's condition (physical or mental), change of medication, diet or fluid intake; Any other information that will facilitate the adequate coordination of care, as reasonably determined by the center. This policy also documents Center will develop a written protocol governing specific responsibilities, policies, and procedures to be used in rendering dialysis services to designated residents at Center, including but not limited to, the development and implementation of a designated resident's care plan relative to the provision of dialysis services. Facility will provide for the interchange of information useful or necessary for the care of the designated resident and will inform Center of a contact person at facility whose responsibilities oversight of provision of dialysis services by Center to the designated residents of the facility. The facility's Post Dialysis Monitoring and Observation with Implanted A-V (arteriovenous) Shunt policy, dated 1/2018, documents To monitor site: Monitor site daily for redness or signs of inflammation. If any bleeding or oozing at the site is noted, apply pressure gauze dressing and notify physician. General Information: When a new A-V access site is created a central line (Central Venous Catheter) is generally used during the healing process (usually several weeks.) Complete the dialysis communication form with any information request by the certified dialysis facility. The facility's Catheter Insertion and Care - Hemodialysis Catheters policy, dated 9/1/16, documents Hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding the use of this catheter. Dressing Change: If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a nurse trained in this procedure. Follow central line dressing change procedure. Bleeding from insertion site: Mild (post- dialysis), this can be expected. Apply pressure to insertion site and contact dialysis center for instructions. Major (post-dialysis), apply pressure to insertion site, contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrives. Documentation: The nurse should document in the resident's medical record every shift as follows: Location of catheter; Condition of dressing (interventions if needed); If dialysis was done during shift; Any part of report from Dialysis Nurse post dialysis being given; Observations post-dialysis. The facility's Nutrition and Hydration to Maintain Skin Integrity policy, dated 8/2008, documents The purpose of this procedure is to provide guidelines for the assessment of resident nutritional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 5 of 12 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 07/11/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. This policy also documents Hydration Evaluation: The specific amount of hydration needed is specific for each resident and fluctuates as the resident's condition fluctuates. Risk factors for dehydration include: Fluid restriction secondary to renal dialysis. Residents Affected - Few R38's current care plan, dated 6/26/24, documents (R38) requires dialysis three times per week at (dialysis center) on Monday, Wednesday and Friday. He has a diagnosis of End Stage Renal Disease. Interventions for the plan of care document Assess for fluid excess. Monitor dialysis access site for signs and symptoms of complications. Notify medical doctor of weight gain and/or fluid volume excess. This plan of care does not document emergency central venous catheter care, complications to watch for at the site, protocols and procedure for venous catheter dressing changes, weight and vital sign parameters or a (dialysis center) specific plan of care for R38's individualized renal dialysis treatment. R38's current Physician Order Sheet, dated 7/10/24 documents R38 has diagnoses of End Stage Renal disease, Type two Diabetes Mellitus and Hypertensive Heart disease with Heart Failure. This order sheet documents R38 has an order for Daily weight- please obtain before breakfast each day. Start date 5/15/24. This Physician order sheet also documents and order for Offer yogurt with all meals, three times a day. Start date 6/28/24. On 7/9/24 at 9:45 AM, R38 was in his room lying in bed. R38's chest and abdomen were uncovered and unclothed. R38's left upper chest mid clavicular line contained a square gauze and tape dressing and had an attached tape covered catheter line dangling. R38 stated he is taken to renal dialysis every Monday, Wednesday and Friday each week. R38 stated, I have a dietary order for yogurt to be with given with every meal. I get it once in a while. There was none this morning. At this time R38's breakfast meal slip was reviewed and did not include yogurt on the list of tray content items. R38's breakfast tray did not have any evidence of a yogurt container or that yogurt was given to R38 with breakfast. R38 stated that he goes to dialysis around 9:00 AM on the scheduled days and doesn't return until around 4:00 PM. R38 stated They never send a sack lunch with me for these appointments. I can only recall two times they did send a sack lunch it was processed lunch meat that I am not supposed to have due to the sodium and phosphorous content. At dialysis they check my weight, not here (at the facility) but I tell them when I get back what I weigh. They (Facility and Dialysis) don't send any paperwork back and forth with me. Just me. The nurses (at the facility) don't do anything with my port. I have had this port (central venous catheter) since January of this year when my old shunt went bad. If I shower, they will cover it or change the dressing when it gets wet but that's all. On 7/9/24 at 12:55 AM, R38's lunch tray was delivered. At this time R38 was sitting in his room on the edge of his bed. R38's lunch tray did not contain any yogurt. R38's electronic medical record does not document any pre or post dialysis monitoring, observations or dressing changes to R38's central venous catheter port. This record also does not contain any documentation of communication between the facility and R38's dialysis administration center. R38's weight record from 5/15/24-7/9/24 does not document daily weights were completed for R38. On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/ Infection Control Preventionist) confirmed that dialysis and the facility do not have any documented communication related to R38's dialysis treatments. V8 stated, Dialysis calls about one time a month and asks about (R38's) changes or issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 6 of 12 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 07/11/2024 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few We look at his central venous catheter, but I don't know that it's charted anywhere. It isn't on the Medication or Treatment Administration record. I can't think of where we would be flagged to chart the assessment, swelling, bleeding or observation of the port anywhere specific. With showers we do cover that area with plastic and may change the dressing if it gets wet. There is no paper transferred back and forth with dialysis. They don't send any communications back with him, nor do we send them a paper on dialysis days. (R38) has had the line in his chest since January I believe. On 7/10/24 at 12:08 PM, V6 (Dietary Manager) stated I don't have any communication with dialysis related to (R38) or their dietician. I am not sure how to talk to them. They (dietary staff) are supposed to be sending (R38) with peanut butter and jelly sandwich or lunch meat or something. The kitchen staff should send that each time he goes out to dialysis, but I don't know if the dialysis facility has a place to keep items cold or not. I don't have any documentation or record to show when sack lunches are sent with (R38) and what contents. They should be giving (R38) yogurt with every meal. I know we got some today so maybe he didn't have it this morning. I am not sure why he wouldn't have gotten yogurt yesterday though. I bet they just forgot to put it on his tray for breakfast and lunch. On 7/10/24 at 12:15 PM, V7 (Cook) stated I work full time and get here about 5:30 AM in the morning. I know we did try to send a sack lunch with (R38) a couple times, but no one ever came and picked up the bag. That was probably a couple weeks ago. I am not aware that (R38) has taken a lunch with him since then. Maybe we should put it on his breakfast tray because he leaves before lunch for his dialysis. On 7/10/24 at 12:43 PM, V3 (Assistant Director of Nursing) stated Dialysis does (R38's) weights before and after treatment at their facility, not here. We don't send any communication plan to dialysis, and they don't send any forms back. I don't have any dialysis plan or specifics for him in his record aside from what we have care planned. V3 confirmed that she doesn't have any documentation to show R38's dialysis catheter port is being assessed, monitored or has dressings changed. On 7/10/24 at 3:15 PM, V2 (Director of Nursing) stated she isn't sure why there is not orders, assessment or nursing documentation to show R38's dialysis port is being assessed or cared for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 7 of 12 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 07/11/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review, the facility failed to identify and monitor targeted psychotic behaviors to warrant the use of Abilify (antipsychotic medication) and attempt a gradual dose reduction of the medication in the past year for one of three residents (R25) reviewed for antipsychotic medications in the sample of 34. Findings include: The facility's Antipsychotic Medication Use policy dated/revised August 2008 documents, The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks. Nursing staff will document an individual's target symptom(s). The Attending Physician will identify, evaluate, and document with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. Based on assessing the resident's symptoms and overall situation, the Physician will determine whether to continue, adjust, or stop existing antipsychotic medication. R25's Physician Order Sheet, order dated 8/18/23, and order start date of 8/19/23, documents R25 has orders for Abilify (aripiprazole) (antipsychotic medication) tablet; 15 mg (milligrams); oral give one tablet orally to be given once a day. This sheet also documents R25's diagnoses for medication is for bipolar disorder, current episode depressed, severe, with psychotic features. R25's Care Plan dated 3/26/24, documents R25 receives antipsychotic medication but does not include R25's specific behaviors to monitor for the use of an antipsychotic medication. This same care plan documents, (R25) makes inappropriate comments to others, has manipulative behaviors, and manic behaviors such as trouble sleeping. R25's Behavior/Intervention Monthly Flow Record dated June and July 2024 documents R25 is being monitored for verbalized sadness, verbalized anxiety, and irritability. This same flow sheet documents R25 has had no behaviors. R25's Medications Flowsheet dated June and July 2024 documents to monitor for inappropriate comments, and verbalized anxiety. This same flow sheet documents R25 has had no behaviors. R25's Electronic Medical Record does not include evidence of a GDR (gradual dose reduction) for Abilify (aripiprazole) tablet; 15 mg (milligrams) or a pharmacy recommendation to conduct a GDR within the last twelve months. V2/Director of Nursing verified a GDR has not been conducted or pharmacy recommendation has not been received for R25 in the last twelve months. V2 stated a GDR should be performed at least every 12 months. On 7/8/24 at 1:36 PM, R25 was sitting in the activities room coloring on her color sheet. No behaviors observed. On 7/9/24 at 1:55 PM, R25 was waiting for the Resident Council Meeting and was calmly coloring and talking to another resident. No behaviors observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 8 of 12 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 07/11/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm On 7/10/24 at 1:25 PM, V2 stated R25's targeted behaviors were inappropriate comments and has not had a gradual dose reduction (GDR) in the past twelve months. V2 stated (R25) targeted behaviors for Abilify are inappropriate comments. V2 stated R25 tries to manipulate and lie but is cooperative most of the time. V2 states, I am trying to reduce the Abilify, but I was told since we are reducing her Buspirone (used as an antidepressant) we are not allowed to reduce both at the same time. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 9 of 12 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 07/11/2024 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on interview and record review, the facility failed to provide food items on the Always Available Menu to residents that requested substitution items from their meals. This has the potential to affect all 70 residents living in the facility. Findings: The document, Food Substitution, no date, states, Residents may be offered a substitute if desired. The Dietary List, Facility Always Available (Foods), no date, states, Chef's Salad; Cottage Cheese; Chicken Nuggets; Deli Sandwich; Cheeseburger; Chicken Salad Sandwich; Egg Salad Sandwich; Ham Salad Sandwich; Tuna Salad Sandwich; Grilled Cheese Sandwich; Peanut Butter and Jelly Sandwich; Lettuce and Tomato Salad; Fruit Plate; French Fries; Mashed Potatoes. On 7/09/24 at the 2:00 PM, Resident Council Meeting, the following residents, (R25, R30, R36, R40, R52), stated, We can get a peanut butter and jelly sandwich and maybe a fruit plate, but that is all that we can get. The Certified Nursing Assistants will ask the [NAME] to make us a grilled cheese, or a cheeseburger with lettuce and tomato or something like that and they tell us that the cook refuses to make them or anything else we ask for. The residents also stated that they are afraid to request anything different from the menu because they will not only not get what they request, but they are served their meals after everyone else gets their meal and it may be cold. The residents also stated that they were not aware of an Always Available Menu, and had not been given this document or offered anything off of it besides the peanut butter and jelly sandwich or fruit plate. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/08/24 and signed by V1, Administrator, documents 70 residents currently reside within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 10 of 12 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 07/11/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to use Cool Down Temperature Logs for potentially hazardous food. This has the potential to affect all 70 residents living in the facility. Residents Affected - Many Findings: The document, Two Stage Cool Down Process, dated 2015, states, Potentially hazardous foods will be cooled properly to prevent food borne illness. Foods will be cooled to proper temperatures. A two stage cooling process will be followed: Stage I: Cool foods from 135 degrees Fahrenheit (F) to 70 degrees F within two (2) hours. Stage II: Cool foods from 70 degrees F to 41 degrees F within four (4) hours. (Total of Six (6) hours.) If prepared from ingredients at room temperature: Cool foods from 70 degrees F to 41 degrees F within four (4) hours. The document, Hazard Analysis Critical Control Point (HACCP) Cooling Log, dated 2024, states, Record temperatures every hour during the cooling cycle. The supervisor of food operation will verify proper cooling procedures by routinely monitoring work activity and reviewing this log. Cooling temperatures will be documented. On 7/08/24 at 10:10 AM, the HACCP Cooling Log was blank for the month of July. There were no other Cool Down Temperature Logs for previous months. On 7/08/24 at 10:15 AM, V6, Dietary Manager, stated, Yes, we do sometimes prepare foods that would be considered hazardous the day before it is served. I just found out a couple of weeks ago that the cool down temperatures are supposed to be recorded. I put the form out and told the cooks to start using the HACCP form, but I guess they forgot. I will make sure the cooks start using the form. The meals for today were prepared today. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 7/08/24 and signed by V1, Administrator, documents 70 residents currently reside within the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 11 of 12 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 07/11/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions for a resident with a Central Venous Catheter dialysis port for one of one resident (R38) reviewed for Dialysis in the sample of 34. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions policy, dated 2023, documents It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multi-drug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. High-Contact resident care activities include: Dressing, Bathing/Showering, Transferring, Provide Hygiene, Changing Linens, Changing Briefs or toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Procedure: Post clear signage on the door/wall outside resident room. Provide isolation cart with personal protective equipment immediately outside resident room. R38's current care plan, dated 6/26/24, documents (R38) requires dialysis three times per week at (dialysis center) on Monday, Wednesday and Friday. He has a diagnosis of End Stage Renal Disease. He currently has a dialysis port to his upper left chest. He has a fistula to his left arm that is not functioning. On 7/9/24 at 9:45 AM R38 was in his room lying in bed. R38's chest and abdomen were uncovered and unclothed. R38's left upper chest mid clavicular line contained a square gauze and tape dressing and had an attached tape covered catheter line dangling. R38 stated he is taken to renal dialysis every Monday, Wednesday and Friday each week. R38 stated, I have had this port (central venous catheter) since January of this year when my old shunt went bad. R38's room did not contain a sign or any personal protective equipment to indicate that R38 was in isolation for enhanced barrier precautions. On 7/10/24 at 12:00 PM, V8 (Licensed Practical Nurse/ Infection Control Preventionist) confirmed that R38 receives dialysis three times a week though a central venous line in his upper left chest and is not on enhanced barrier precautions. V8 stated We look at his central venous catheter, but I don't know that it's charted anywhere. (R38) hasn't been on any recent isolation that I recall of any kind. He has had the line in his chest since January I believe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145726 If continuation sheet Page 12 of 12