Inspection·February 27, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm with the IV pump attached to it, and the two IV poles swayed when moved or touched the slightest bit. The poles appeared loose at the point where the IV pole attached to the wheeled base. R4 said, when the incident happened, she had pushed the lid to the ice machine up so she could reach inside the machine to retrieve ice. R4 said as she lifted the ice machine lid, the lid to the ice machine hit one of the IV poles and caused the IV pole to fall and hit her right shin. Residents Affected - Few On February 26, 2025 at 12:37 PM, R4 was sitting in her wheelchair in the hallway. V2 (DON-Director of Nursing) approached R4 and asked about the elastic compression bandage on R4's right lower leg. R4 said, Yesterday, I was in the ice machine room and a pole fell on my leg. R4 denied falling. V2 removed the elastic compression bandage from R4's right lower leg. The front of R4's right lower leg was bright red in color on her shin, approximately two inches wide, from just under her right knee to her ankle. No open skin areas were noted. V2 touched R4's right reddened shin area and said the area was not warm to the touch. R4 flinched when V2 touched her right shin. V2 rewrapped R4's right shin with the elastic compression bandage and asked R4's nurse to provide R4 with her ordered narcotic pain medication. V2 continued to say she heard commotion in the ice machine room the day before. V2 said she saw R4 come from the ice machine room but was not aware R4 had been injured. On February 26, 2025 at approximately 4:00 PM, R4 was sitting in her wheelchair in her room, sorting her colored pencils. R4 said the pain in her right lower leg had improved since she took the narcotic pain medication earlier. R4 again said, I did not fall. My leg got hurt in the ice machine room when a pole fell and hit my leg. R4's hospital discharge records dated February 25, 2025 show R4 was treated for a contusion to her lower extremity. The discharge instructions show to apply rest, ice, compression, and elevation to her lower extremity. R4's X-ray results of her right tibia and fibula dated February 25, 2025 show: Clinical indication: Bruising anterior mid-shaft right tibia. Findings: Two views right tibia and fibula were obtained. No fracture or dislocation is seen. Bones are intact. Hospital physician documentation shows: Right anterior shin tenderness and soft tissue swelling. There is ecchymosis. No erythema. No open wounds, bleeding, or lacerations. No palpable warmth. There is no obvious deformity. On February 26, 2025 at 1:42 PM, V14 (RN-Registered Nurse) said, I was the nurse on duty yesterday. I worked a double. I worked day shift and afternoon shift. [R4] came up to me and she told me she went into the ice room, and she bumped her leg on something. We offered to do an X-ray, but she said no, and the family called me after that. The family member called the doctor and the doctor said send her out. She went out to the hospital and when she came back from the hospital, the paperwork said she just had bruises. It looked like she bumped her leg. It was red. There were no black and blue marks. She did not fall. On February 27, 2025 at 8:07 AM, V20 (Maintenance Director) said, I was not aware there were any IV poles that were wobbly or needed to be repaired. That is a simple fix. There is a screw under the base that needs tightening to keep the pole from wobbling. Sometimes we have been running out of storage space, and temporarily we have been storing stuff in the ice machine room. There was an issue with the door knob, and I put a temporary one on the one door. The new door knob did not have a lock on it. The room is meant to be locked and residents are not supposed to access the room. On February 27, 2025 at 11:36 AM, V2 (DON) said, Residents are not supposed to go into the ice machine room. The room is usually locked, but the lock was broken. We should not have been storing (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 02/27/2025 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 0689 equipment in that room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145795 If continuation sheet Page 3 of 3