Tower Hill Healthcare Center

In the surveyor’s words

From the most serious findings on record at Tower Hill Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 15, 2024

  Deficiencies at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to protect R102 from physical abuse, resulting in R102 having muscular skeletal pain to his left arm and redness and swelling to his left cheek for 1 of 32 residents (R102) reviewed for abuse in the sample of 32. The Immediate Jeopardy began on 03/09/2024 at 5:30AM, when V37, CNA-Certified Nursing Assistant, became aggressive with R102, by pinning R102's hands to his chest and bearing all his weight on to R102. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. […]

• Immediate jeopardy, isolatedF607Mar 15, 2024

  Based on observation, interview, and record review, the facility failed to follow their abuse policy and procedure by not protecting R102 from abuse by not removing a staff members who's observed actions were suspected to be abusive, and not performing a full body assessment of a resident who was suspected of being abused for 1 of 36 residents (R102) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. […]

• Immediate jeopardy, isolatedF609Mar 15, 2024

  Based on observation, interview, and record review the facility failed to immediately report a suspicion of physical abuse for 1 of 36 residents (R102), and failed to ensure and allegation of verbal abuse was immediately reported for 1 of 32 residents (R80) reviewed for abuse in the sample of 36. The Immediate Jeopardy began on 03/09/2024 at 12:30AM, when V38, CNA-Certified Nursing Assistant, failed to report her suspicion of abuse when she observed V37, CNA, becoming aggressive, grabbing R102's hands and pinning them down to R102's chest, resulting in R102 being abused by V37, CNA, at 5:30AM. V1, Administrator, was notified of the Immediate Jeopardy on 03/14/2024 at 4:00 PM. […]

• Actual harm, isolatedF686Apr 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident, who was at risk for skin breakdown, was kept clean and dry, and did not develop a pressure ulcer.This failure resulted in the development of a stage 2 pressure ulcer to the resident's buttock. This applies to 1 or 3 residents (R1) reviewed for improper nursing care in the sample of 8. Findings include: R1's electronic medical record showed R1 to be [AGE] years old and admitted to the facility with diagnoses that include muscle weakness, unsteadiness on feet, other lack of coordination, acute kidney failure, dysphagia, schizophrenia, schizoaffective disorder, generalized anxiety disorder, and syncope and collapse. […]

• Actual harm, isolatedF600May 16, 2024

  Based on interviews and record reviews, the facility failed to protect residents from abuse per their facility abuse prevention program. This applies to 3 of 4 residents (R1, R3 and R4) reviewed for abuse in the sample of 6. The failure resulted in R1 experiencing ongoing head, neck and shoulder pain as a result of R2 hitting R1. The findings include: 1. Face sheet, dated 5/15/24, shows R2's diagnoses included dementia, psychosis, muscle weakness, malignant neoplasm of bladder, cognitive communication deficit, reduced mobility, and history of falling. […]