F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on interview and record review the facility failed to maintain a residents dignity by not answering a
call light in a timely manner for 1 of 3 residents (R1) reviewed for dignity and resident rights in the sample of
5.
The findings include:
On 3/18/25 at 10:00 AM, V15 (R1's great - granddaughter) stated her and a relative were visiting R1 on
3/9/25. When she arrived around 11:30 AM, R1 needed to use the bathroom and her call light was on. V15
stated they went to the nurse's station to get a staff member because no one came to help. V15 stated she
went and asked again because no one had come to help R1 and was told they would be down in a few
minutes. V15 stated no one came to R1's room to toilet her. V15 stated she went and asked for assistance
again and was told they were in the middle of lunch, needed to pass trays, and had other people to help.
V15 stated by the time she got back to R1's room, R1 had wet herself. V15 stated R1 had to sit like that for
awhile (10-20 minutes) and that is not right. V15 stated no one should have to sit in it. V15 stated it took 40
minutes - 60 minutes for anyone to come and help her. V15 stated R1 gets embarrassed about things like
this and it upsets her. V15 stated R1 has dementia so she would not remember the incident but it does
embarrass R1. V15 stated R1 uses a bedpan for toileting and knows when she has to use the toilet.
On 3/18/25 at 1:34 PM, V11 (R1's daughter/emergency contact) stated, it can take between 5 minutes - 45
minutes for R1's call light to be answered when R1 remembers to use it. Recently my brother and
granddaughter were there to see R1. They said R1 had to go to the bathroom and it took three times asking
for help before R1 got any help and by that time R1 had wet herself.
On 3/18/25 at 2:02 PM, V16 (Activity Director) stated, at the February (2025) resident Council Meeting
there were complaints about call lights. They said it takes longer for their call lights to be answered after
meals.
On 3/18/25 at 2:19 PM, V3 DON (Director of Nursing) stated, the facility does not have a system in place to
track call light response time. V3 stated staff try to answer call lights as soon as possible and have a CNA
(Certified Nursing Assistant) designated in each group to answer call lights. V3 stated on average it takes 3
minutes to 10-15 minutes to answer a call light. V3 stated there is a manager that walks the floor that can
answer the call lights. V3 stated if a call light is not answered in 45 minutes or longer it is not acceptable. V3
stated when a call light goes off it should be answered right away. If staff say they are going to be there in a
few minutes to help the resident then they should honor that.
(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 2
Event ID:
145795
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
03/18/2025
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 0550
Level of Harm - Minimal harm
or potential for actual harm
The Rehabilitation Nurse Practitioner Progress Note dated 3/13/25 for R1 showed R1 requires maximum
assistance for bed mobility and transfers. R1 has impaired mobility, transfers, and activities of daily living.
R1's Interim Care Care Plan (no date) for her admission date of 2/26/25 did not show a plan in place for
activities of daily living including toileting needs and/or incontinence.
Residents Affected - Few
The Face Sheet dated 3/18/25 for R1 showed diagnoses including encephalopathy, muscle weakness,
unsteadiness on feet, repeated falls, hypothyroidism, hypertension, chronic kidney disease, bradycardia,
heart failure, morbid obesity, and diverticulosis.
The facility's Dignity policy (3/2024) showed, each resident shall be cared for in a manner that promotes
and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and
respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. Staff
shall promote dignity and assist residents as needed by: promptly responding to the residents request for
toileting assistance
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145795
If continuation sheet
Page 2 of 2
