Inspection·December 14, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review and interview the facility failed to notify the physician of a resident not receiving a physician ordered enteral nutrition formula by gastrostomy tube for one of three residents (R1) reviewed for physician notification in the sample of three. Findings include: The facility's Gastric Tube Feeding via Continuous Pump policy dated 08/2008 documents, Purpose: The purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally. Verify compliance with physician's order, including the product volume and infusion rate. Report any complications promptly to the physician. 1. R1's Hospital Discharge Orders dated 11-21-24 document, Tube Feeding: Osmolite 1.5 at a goal rate of 45 ml (milliliter) per hour. R1's Medications Flowsheet dated 11-21-24 (R1's Admission) through 11-30-24 documents R1 did not receive her physician ordered Osmolite 1.5 calorie/ml (milliliter) at 45 ml per hour via gastrostomy tube on 11-21-24 through 11-25-24. R1's Medical Record does not include documentation of a physician being notified of R1 not receiving her physician ordered Osmolite nutritional tube feeding as ordered from 11-21-24 through 11-25-24. On 12-13-24 at 2:30 PM V2 (Director of Nursing) stated, The nurses did not call the physician or gastroenterology specialist to let them know that they did not have Osmolite to administer to (R1) as ordered. The nurses should have called the physician to get an order for a substitute formula until we (the facility) were able to get the Osmolite. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145726 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 12/14/2024 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)