Inspection·January 7, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on observation, interview and record review the facility failed to ensure residents were free from physical abuse. This applies to 3 of 4 residents (R2, R4, R5) reviewed for abuse in the sample of 13. The findings include: 1. The facility's undated Final Abuse Investigation shows (R4) is male resident with diagnoses including unspecified dementia, restlessness and agitation, generalized muscle weakness, vascular dementia, and osteoarthritis. (R4) is alert and oriented x1 with severe cognitive impairments with short- and long-term memory, judgement and decision-making abilities. He relies on staff for cueing and redirection, often paces the facility and has exit seeking behaviors. He tends to wander around the unit and requires frequent redirection.(R5) is a female resident with diagnoses including other psychotic disorder, major depressive disorder, generalized anxiety, glaucoma, and cognitive communication deficit. (R5) is alert and oriented x 1-2 with severe cognitive impairments and also has impaired short- and long-term memory, judgement and decision-making abilities. On 9/29/25, V14 (Certified Nursing Assistant-CNA) responded to (R5's) room due to sounds of screaming. V14 witnessed (R4) strike (R5) in the chest.(R5) reported (R4) kept coming into her room and wouldn't leave. (R5) stated she tried to physically get (R4) to leave her room and scratched him trying to get him out. (R5) stated she grabbed (R4) to pull him out of the room and (R4) punched her. (R4) reported (R5) attacked him and that he attempted to stop her. On 01/7/26 at 9:12 AM R5 was in her room sitting in her bed. R5's room was located across the nurse's station. R5 was alert to self and forgetful. She said she was trying to get away from a man and she was not going to let the man hurt her. R5 was not able to recall the details of the incident but stated, I wanted to get away from him. On 01/7/26 at 11:10 AM, V3 (Social Services) said R4 has a history of wandering, aggressive, verbal and physical behaviors. R4 is an elopement risk with impaired cognitive deficits. On 9/29/25, R4 wandered into R5's room and put his hands on R5. A staff member witnessed R4 punch R5 in the chest. We do our best to monitor residents, but we can't keep eye on everyone. R4 should be monitored when he is out of his room because of his behaviors. R5 has dementia as well and gets very confused and has a history of past experiences of abuse and probably felt threatened by R4. R4 was sent out for his behaviors and was transferred to another facility. On 01/7/26 at 12:50 PM, V10 (Licensed Practical Nurse-LPN) said on 9/25/25, she was informed by V14 (CNA) R4 wandered into R5's room. R5 was trying to shove R4 out of her room and she witnessed R4 punch R5 in the chest. R4 has a history of wandering and is high risk of elopement. R4 is cognitively impaired with behaviors of agitation towards staff and can be difficult to redirect at times. On 1/7/26 at 1:35 PM, V1 (Administrator) said she is the abuse coordinator. Any allegations of abuse should be reported immediately. Residents are separated immediately if staff witness abuse. V1 confirmed R4 and R5's incident was witnessed by staff and physical abuse was substantiated. 2. The facility's undated Final Abuse Report shows (R2) is a female resident with diagnoses including dementia, anxiety, insomnia, GERD, rheumatoid arthritis, and spinal stenosis. (R2) is alert and oriented x2 with moderate cognitive (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 3 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 01/07/2026 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)