Inspection·December 26, 2024

F 0600 attempted to reach out to V6 and V7 via telephone. However, they did not pick up their phones. Level of Harm - Minimal harm or potential for actual harm On 12/24/24 at 11:05 AM, V8 (CNA) and V9 (CNA) were interviewed together. V8 stated that another resident came and told her that (R1) and (R2) were fighting. V8 said she heard the commotion and noise and went to the dining room. She stated, We separated them and took (R1) to his room. (R2) was taken to the nursing station. What I heard was that (R2) left his tray and stepped away to get something. (R1) walked in and started eating from (R2)'s tray. Then it got physical and (R1) punched (R2). V9 stated, When I got to the dining room, they were already separated. I talked to (R2) and he said that (R1) punched him. (R2) stated he didn't want any problems. They were put on 1:1. (R2) went to the hospital. Both V8 and V9 stated this was physical abuse. Residents Affected - Few Final incident report between R1 and R2 shows the following: On November 26, 2024, (R1) and (R2) were both noted to be in the dining room for dinner. (R1) and (R2) were observed to be in an altercation when staff immediately intervened. Residents were separated and assessed for injury. (R1) was noted with scratches to the upper chest and neck area. (R2) was not observed to have any injuries. (R2) reported that (R1) hit him when (R2) was attempting to redirect him. (R1) was not able to provide any information. (R1) was placed on a 1:1. On November 26, 2024, (R1) and (R2) were both residing on the second floor in different rooms. (R1) and (R2) were in the dining area for dinner. Staff heard a disturbance/commotion and observed (R1) and (R2) engaging in a physical altercation. Staff immediately intervened and separated both residents to ensure their safety and assess the situation. Both residents were also assessed for injuries. (R1) was noted with scratch marks to his chest. (R2) was not noted with any injuries. Upon interviewing (R1), he was unable to identify any details of the incident other than he was hit and denied hitting anyone. (R2) when interviewed, stated that he left the dining area and then upon return, (R1) was observed to be eating his food. When he told him to stop, (R1) allegedly hit (R2) and then the two proceeded to engage in a physical altercation until staff were able to separate them. (R1) was placed on a 1:1. Both residents (R1) and (R2) were sent to the hospital for evaluation. The facility conducted a thorough investigation pertaining to an allegation of physical abuse regarding two residents. Both (R1) and (R2) provided statements that do support a resident-on-resident altercation did occur however the facility is unable to determine the aggressor or the victim or any other concrete evidence to support a clear determination regarding a victim of abuse. R1's face sheet shows an admission date on 3/16/24. R1's face sheet shows diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, restlessness and agitation, and major depressive disorder. R1's MDS (Minimum Data Set) dated 9/26/24 shows a BIMS (Brief Interview for Mental Status) score of 9 which means he is moderately impaired in cognition. R1's risk assessment dated [DATE] shows: Nurse on duty was passing medication by nurses station and heard a commotion in the dining room. Nurse went to dining room immediately and observed (R1) and another resident (R2) lying on the floor on their bottoms and in the process of standing up. Nurse was told by aides that the residents were fighting and they separated them. (R2) told nurse that (R1) took his food. (R2) said to give it back and (R1) got aggressive and hit him. (R2) hit him back and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145795 If continuation sheet Page 2 of 3 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 145795 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tower Hill Healthcare Center 759 Kane Street South Elgin, IL 60177 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 - Minimal harm or potential for actual harm Residents Affected - Few began to choke him. (R1) stated that (R2) hit him. He offered no further explanation despite nurse asking various other questions. Both residents were assessed by the nurses. (R1) was noted with a scratch under his right ear, scant bleeding, which stopped with direct pressure. Noted with scratches to the neck and upper chest. Both residents were sent to the ER (Emergency Room) for evaluation/treatment. R1's care plan shows (R1) may be at risk for abuse related to mental/emotional challenges as evidenced by (R1)'s current mental status, dementia. Goal: (R1) will remain free from harm through the next review date. Interventions: Assure (R1) that they are in a safe and secure environment with caring professionals. R1's progress note dated 12/9/24 at 11:00 AM shows that R1 had a large mass on neck. He was sent out to hospital for evaluation and treatment. Hence, surveyor was unable to interview R1. R2's face sheet shows an admission date of 5/23/24. R2's face sheet shows diagnoses of violent behavior, major depressive disorder, recurrent, moderate, Alzheimer's disease, unspecified, other amnesia, vascular dementia, unspecified severity, with other behavioral disturbance, anxiety disorder, and cognitive communication deficit. R2's MDS dated [DATE] shows a BIMS score of 8, which means he is moderately impaired in cognition. R2's risk assessment dated [DATE] shows the following: Another resident alerted the nurse and aide of possible altercation in the dining room between (R2) and (R1)-aggressor. Immediately upon notification, nurse and aides began heading towards dining room when a loud clatter and thump was heard. Upon entering the dining room, nurse observed (R1) on top of (R2) with his hands around (R2)'s neck. The aides quickly separated the 2 men and removed (R1) from the dining room. Nurse assessed (R2) and obtained vitals. (R2) stated he left the dining room for a glass of water and when he returned, (R1) was eating his food. (R2) then told (R1) that the food he was eating was his and he attempted to remove his plate from him. (R1) then punched him in the left jaw and the next thing he knew, (R1) was on the floor and (R2) was choking him. (R1) and (R2) were separated. (R1) was escorted to his room. (R2) was transferred to the hospital for further evaluation. R2's care plan shows: (R2) may be at risk for abuse related to mental and emotional challenges as evidenced by medical diagnoses of dementia. (R2) will remain free from harm through the next review date. Assure resident that they are in a safe and secure environment with caring professionals. Facility Abuse Prevention Program, revised 1/2019, shows, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (whether or not actually given) . Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145795 If continuation sheet Page 3 of 3