Tower Hill Healthcare Center: Coffee Burn Violation - IL
A resident at Tower Hill Healthcare Center, a man with multiple sclerosis and dementia, suffered a second-degree burn on his left inner thigh after spilling hot coffee in his lap. He was sitting in the dining room when it happened. Staff brought him to his room, removed his pants, and applied ice. A wound nurse responded and found the skin red; she applied ice and silver burn cream. Within days, two small blisters had formed.
The burn measured 3.5 centimeters by 2.8 centimeters. The wound note, dated April 8, 2026, documented a second-degree burn and recorded the application of an ice pack to prevent further skin breakdown.
When a state inspector arrived on April 24, 2026, the resident was in the dining room watching a movie. He said he liked the coffee at the facility. He said a few days ago he spilled some in his lap, but it was all healed up now. He said the coffee wasn't too hot. He liked it just the way it was.
The wound nurse, a licensed practical nurse, told the inspector what actually happened. The resident had been in the dining room when the spill occurred. The burn was real, the blisters were real, and the wound was still being treated.
Later that morning, the inspector watched the resident receive coffee at the noon meal. He was served in a plastic mug with a handle. He added powdered creamer, stirred it, and drank it with one hand on the handle and one hand on the side of the cup. His grip looked steady. His hands weren't shaking.
The explanation for why that hadn't happened on the day of the burn came from the assistant director of nursing, who spoke with the inspector at 12:45 in the afternoon. She said the resident didn't need feeding cues or any help eating or drinking. She said he hadn't had any issues with coffee in the past. Then she said this: the facility didn't have enough handled mugs, so staff had been using Styrofoam cups instead. Styrofoam cups have no handles.
She said the facility had since ordered more handled mugs. She said residents would no longer be served hot beverages in Styrofoam.
The resident's diagnoses, multiple sclerosis and dementia, were listed on his face sheet. Multiple sclerosis can affect grip strength, coordination, and muscle control, though the degree varies by individual. The inspection report noted his grip appeared secure on the day of the observation. What it could not establish was whether that was true on the day he was handed a hot beverage in a handleless cup.
The facility's own policy, written in 2017, required that hot beverages be provided to residents in a safe manner. The policy did not describe what to do when the equipment meant to make that possible ran out.
By the time the inspector left, the wound had shrunk. A follow-up assessment showed the burn site measuring 0.8 centimeters by 0.5 centimeters, with 90 percent intact skin and 10 percent pale pink non-granulating tissue. The facility called the deficiency one of minimal harm or potential for actual harm.
The resident, sitting in his wheelchair in the dining room that morning, said the coffee was fine. He said it wasn't too hot. He said the burn had healed up.
He didn't mention the Styrofoam cup.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tower Hill Healthcare Center from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
TOWER HILL HEALTHCARE CENTER in SOUTH ELGIN, IL was cited for violations during a health inspection on April 24, 2026.
He was sitting in the dining room when it happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.