Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to accurately assess a resident's risk of abuse and failed to
adequately supervise a resident to prevent resident-to-resident physical abuse for two of three residents
(R2 and R3) reviewed for abuse in the sample of four. These findings resulted in R2 and R3 physically
assaulting each other and R3 experiencing pain, ongoing increased anxiety, fear, and restlessness.Findings
Include:The facility's Abuse and Retaliation Policy Prevention Program Policy dated 1/2026 documents,
Policy: The facility affirms the right of our resident to be free from abuse, neglect, exploitation, retaliation,
misappropriation or property, deprivation of goods and services by staff, or mistreatment. The facility
therefore prohibits abuse, neglect, exploitation, misappropriation or property, and mistreatment of residents.
In order to do so, the facility has attempted to establish a resident-sensitive and resident-secure
environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to
prevent occurrences of abuse, neglect, exploitation, misappropriation or property, deprivation of goods and
services by staff, and mistreatment of residents. Abuse means any physical or mental injury, retaliation, or
sexual assault inflicted upon a resident other than by accidental means. Physical Abuse is the infliction of
injury on a resident that occurs other than by accidental means, and that requires medical attention.
Physical abuse including hitting, slapping, pinching, kicking, and controlling behavior through corporal
punishment. Sexual abuse included, but is not limited to, sexual harassment, sexual coercion, or sexual
assault including non-consensual or non-competent to consent sexual activity. Resident Assessment: As
part of the resident's life history on the admission assessment, comprehensive care plan, and MDS
(Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse,
neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have
needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will
identify any problems, goals, and approaches that would reduce the changes of abuse, neglect,
exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to
monitor the goals and approaches regularly and update as necessary.1.R2's MDS (Minimum Data Set)
assessment dated [DATE] documents R2 was severely cognitively impaired.R2's current Face Sheet
documents R2 was a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Vascular
Dementia with other behavioral disturbance, Schizoaffective Disorder, and Delusional Disorder. This same
Face Sheet documents R2 expired on [DATE].R2's Progress Notes dated [DATE] at 11:26 PM and signed
by V3 (Registered Nurse/RN) document, This nurse heard yelling from the middle hall. Upon entering room
noted (R2) wheeling out of a female resident's room (R3's). (R3) stated that (R2) allegedly crawled on top
of (R3) in her bed and punched (R3) on the right side of (R3's) face three times and then (R3) punched
(R2) back and (R3) pushed (R2) off of (R3). This same note documents R2 was sent to the emergency
room for psychiatric treatment due to
(continued on next page)
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 4
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
02/15/2026
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 0600
Level of Harm - Actual harm
Residents Affected - Few
increased agitation.R2's Hospital Emergency Department Notes dated [DATE] document, You (R2) were
seen in the emergency department on [DATE] with the chief complaint of combative. EMS (Emergency
Medical Services) report that (R2) allegedly hit another resident (R3) earlier today.2.R3's MDS assessment
dated [DATE] documents R3 is cognitively intact and has no behaviors.R3's current Face Sheet documents
R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Chronic Obstructive
Pulmonary Disease, Hypertension, Generalized Anxiety Disorder, and Insomnia.R3's Progress Notes dated
[DATE] at 11:38 PM and signed by V3 (RN) document, 10:00 PM (R3) states a male resident (R2) allegedly
crawled on top of (R3) and punched (R3) three times to the right side of (R3's) face. (R3) assessed for
injuries with no injuries noted. No redness noted to face. (R3) asked if she feels safe to stay in her room
and she states she does feel safe. (R3) assured that we (facility staff) would shut her door and monitor the
hallway. No complaints of pain or distress noted. Bed in low position with call light in reach. Will continue to
monitor.R3's Physician's Progress Notes dated [DATE] and signed by V10 (Psychiatric Advanced Practical
Nurse/APN) document, APN met with (R3) to discuss recent increase in anxiety symptoms. Today (R3)
describes a triggering event in which another resident (R2) entered (R3's) room, confused, and attempted
to climb on (R3's) bed. This triggered fear and anxiety in (R3). Describes thoughts that (R3) may have
caused or contributed to this (happening). (R3) interested in therapy to further process. Continued leg
bouncing and describes feeling restless.R3's Physician's Progress Notes dated [DATE] and signed by V10
document, APN met with (R3) to discuss recent increase in anxiety concerns. Last visit increased Prozac
dosage. Discussed increase in Hydroxyzine. Today (R3) reports continued concerns with anxiety and worry.
Reports feeling recent incident of other resident (R2) coming in (R3's) room and trying to get on (R3's) bed
was somehow her fault. Discuss plans to further process this with therapist.R3's Physician's Orders dated
[DATE] and signed by V10 (APN) document, Increase Prozac from 10 mg (milligrams) to 20 mg daily.
Change Hydroxyzine 50 mg BID (twice daily) PRN (as needed) to BID scheduled.R3's Physician's Orders
dated [DATE] and signed by V10 document, Change Hydroxyzine 50 mg BID to 25 mg TID (three times
daily).R3's current Care Plan documents R3 has episodes of anxiety. This same Care Plan does not
address R3's allegations of abuse or any interventions to address or protect R3 from R2 after R3 made
allegations of resident-to-resident (R2 to R3) abuse on [DATE].R3's Abuse Risk Review dated [DATE] and
signed by V8 (Social Service Director) documents R3 has not experienced or made allegations of any type
of abuse (including resident-to-resident altercations) since the last review dated [DATE], therefore no further
care plan recommendations were needed.On [DATE] at 9:30 AM R3 was lying in bed. R3 stated, A few
months ago, (R2) kept trying to have a relationship with me and I was not interested. (R2) lived in the room
next to me. One time (R2) came up to me in the hallway and tried to touch my breasts. I blocked (R2) from
touching my breasts. I told the staff. I cannot recall who I reported this too. It was too long ago. (R2) would
always follow me around in the hallways and I would have to tell (R2) Leave me alone! I am not a whore! I
did not want any kind of relationship with (R2). One night ([DATE]) I had dozed off asleep and woke up to
(R2) rubbing my stomach. (R2) had his knees on my bed (left side of the bed) and was leaning over me. I
yelled for help and yelled at (R2) to, Get the h**l off of me and get out of my room! (R2) started punching
me in the head. It hurt my head. I drew my fist back and hit (R2). When I hit (R2) it knocked (R2) backwards
and (R2) got back into (R2's) wheelchair. I was stunned and traumatized. I felt like (R2) was going to try and
sexually attack me. Since then, I have been afraid and scared of men. I sleep in my shorts and a jacket
every night, so I do not expose myself and have had to start seeing a therapist to help me cope with what
(R2) did to me. How would you feel if a man came into your room during the night and you were woken up
to that? I was so
(continued on next page)
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
02/15/2026
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 0600
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
scared.On [DATE] at 11:25 AM R4 was sitting in a wheelchair in her room. R4 stated, On ([DATE]) I was
lying in bed and was woke up to (R3) yelling of help and no one came to help (R3). I saw (R2) crawling on
top of (R3) in bed. (R3) was trying to get (R2) off of her. I saw (R3) hitting (R2) and (R2) finally got off (R2)
and got back into his wheelchair. (R3) told me that (R2) hit her on the head. (R2) had tried to come into our
room several nights before this. I was scared of (R2) and did not want (R2) to do anything to me. I told
(V1/Administrator) everything that (R2) did to (R3) that night.On [DATE] at 12:30 PM V8 (Social Service
Director) stated, I completed (R3's) abuse risk review on [DATE] and it is inaccurate. When I completed the
abuse risk I did not know that (R3) had made an allegation of abuse on [DATE]. At this time V8 confirmed
R3's care plan has not been updated with interventions to address R3's abuse allegations or with
interventions to protect R3 from further abuse or address R3's increase in anxiety or fear.On [DATE] at 2:00
PM V10 (Psychiatric APN) stated I have been seeing (R3) monthly. (R3) was really upset and anxious
about (R2) coming into her room. (R3) kept feeling like she was dressing wrong and giving (R2) the wrong
impression. I told (R3) it was not her fault. I have had to increase (R3's) medications to try and treat (R3's)
anxiety from this.On [DATE] at 8:20 PM V3 (RN) stated, On the night of [DATE] I heard (R3) screaming for
help. I went to (R3's) room and (R2) was in his wheelchair in (R2's) room. (R3) told me (R2) got in bed with
her and (R2) hit (R3) in the head. (R3) stated she hit (R3) back. (R2) was showing signs of increased mania
that night and should not have been in (R3's) room. (R2) was capable of transferring himself from his
wheelchair into (R3's) bed. (R3) would have no reason to lie. I sent (R2) to the emergency room
immediately for treatment. It was not safe to leave (R2) in the building with the behaviors (R2) was having. I
immediately called (V1/Administrator) and told (V1) that (R3) reported that (R2) got in bed with (R3) and hit
(R3) in the head, and (R3) hit (R2) back.
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
02/15/2026
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 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to thoroughly investigate an allegation of
resident-to-resident physical abuse for two of three residents (R2 and R3) reviewed for abuse in the sample
of four.Findings include:The facility's Abuse and Retaliation Policy Prevention Program Policy dated 1/2026
documents, Internal Investigation: Any incident or allegation involving abuse, neglect, exploitation,
retaliation, mistreatment, or misappropriation or resident property will result in an investigation. Investigation
Procedures: The appointed investigation will, at a minimum, attempt to interview the person who reported
the incident, anyone likely to have direct knowledge of the incident, and the resident, if interviewable. Any
written statements that have been submitted will be reviewed, along with any pertinent medical record or
other documents.R2's Progress Notes dated 1/2/26 at 11:26 PM and signed by V3 (Registered Nurse/RN)
document, This nurse heard yelling from the middle hall. Upon entering room noted (R2) wheeling out of a
female resident's room (R3's). (R3) stated that (R2) allegedly crawled on top of (R3) in her bed and
punched (R3) on the right side of (R3's) face three times and then (R3) punched (R2) back and (R3)
pushed (R2) off of (R3). This same note documents R2 was sent to the emergency room for psychiatric
treatment due to increased agitation.R2's Hospital Emergency Department Notes dated 1/2/26 document,
You (R2) were seen in the emergency department on 1/3/26 with the chief complaint of combative. EMS
(Emergency Medical Services) report that (R2) allegedly hit another resident (R3) earlier today.R3's
Progress Notes dated 1/2/26 at 11:38 PM and signed by V3 (RN) document, 10:00 PM (R3) states a male
resident (R2) allegedly crawled on top of (R3) and punched (R3) three times to the right side of (R3's) face.
(R3) assessed for injuries with no injuries noted. No redness noted to face. (R3) asked if she feels safe to
stay in her room and she states she does feel safe. (R3) assured that we (facility staff) would shut her door
and monitor the hallway. No complaints of pain or distress noted. Bed in low position with call light in reach.
Will continue to monitor.R2 and R3's Abuse Investigations and Witness Statements dated 1/2/26 through
1/6/26 and signed by V1 (Administrator) only include two statements obtained from R4 and V3 (RN) and
does not include documentation of R2 crawling on top of R3 and hitting R3, or R2 hitting R3 back.On
2/14/26 at 11:00 AM V1 (Administrator) stated, I am sorry. I did not know (R2) hit (R3) and (R3) hit (R2)
back (on 1/2/26). I only have interviews from (V3) and (R4/R3's Roommate). I did not interview anyone else
regarding the incident and did not know (V3) had charted that (R2) and (R3) had hit each other. At this time
V1 verified the abuse investigation should have been more thorough and should have included more
statements from other staff working and other residents. V1 also verified her abuse investigation did not
identify that R2 and R3 had hit each other.On 2/14/26 at 8:20 PM V3 (RN) stated, I reported to (V1)
immediately on 1/2/26 that (R3) reported (R2) was on top of (R3) in bed and hit (R3) in the head. I also
reported that (R3) hit (R2) back.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145726
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
FAQ · About this visit
Common questions about this visit
What happened during the February 15, 2026 survey of TIMBER POINT HEALTHCARE CENTER?
This was a inspection survey of TIMBER POINT HEALTHCARE CENTER on February 15, 2026. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TIMBER POINT HEALTHCARE CENTER on February 15, 2026?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.