Country Villa Wellness & Rehabilitation

Review of the

trying to get in the bed and fell, resident did not hit his/her head.

Family and physician aware no new orders.

Denies any pain or discomfort at this time;-Resident Description: Resident Unable to give description;-Was this incident witnessed: No;-Injury type: No injuries observed at time of incident;-People Notified: None listed.

Review of the resident's medical record, showed no neuro checks completed for the unwitnessed fall. 4.

During an interview on 2/20/26 at 11:06 A.M., the Interim Director of Nursing (DON) and the Previous Administrator (PA) said they expected staff to be knowledgeable of and to follow facility policies and procedures. If a resident had a fall, they expected the nurse to complete a head to toe assessment, including obtaining vital signs and starting neuro checks if the fall was unwitnessed or if the resident hit their head.

They expected notifications to be made to the physician, family/Resident Representative (RR) and the DON.

They expected the notifications to be documented in the incident report and/or progress note.

They expected post-fall monitoring to be completed for 72 hours after the fall.

They expected documentation of the post fall monitoring to be completed in the resident's progress notes once per shift for 72 hours.

They expected vital signs to be completed each shift if neuro checks were not being completed and for them to be documented in the progress note or placed in the resident's medical record under vital signs.

265343 02/26/2026

Country Villa Wellness & Rehabilitation 850 Country Manor Lane Creve Coeur, MO 63141

Review of the resident's annual MDS, dated [DATE], showed cognitively intact.

Review of the resident's care plan, dated 12/9/25, showed:-Problem: Resident required cares in pairs with activities of daily living (ADL, bathing, dressing, eating, toileting, and transferring) assistance due to history of embellished stories and transferred full body lift with three people;-Goal: Needs will be met and cares provided safely through next review.

Review of the resident's progress notes dated 2/17/26 through 2/19/26, showed:-No progress note of an incident on 2/17/26;-On 2/18/26 at 4:34 P.M., staff documented the resident stated that on 2/17/25 at 4:00 P.M. two agency Certified Nurse Aides (CNAs) were putting him/her into the Hoyer lift and were turning him/her without informing him/her first.

Once resident was in the Hoyer and was being lowered into his/her chair, the crossbar on the Hoyer scraped his/her hand and wrist.

The resident yelled stop, but the staff was trying to get him/her out of the air and into his/her seat.

Resident had a skin tear on his/her hand with a dressing on it and he/she had a bruise on his/her wrist.

Resident admitted that he/she refused to cross his/her arms while in the Hoyer because he/she was afraid of falling again;-No progress notes for post-incident monitoring.

Further review of the resident's medical record, showed:-No incident report completed on 2/17/26;-No skin assessment completed on 2/17/26;-No notifications to physician and RR.

Observation on 2/19/26 at 1:33 P.M., showed the resident had bruising on top of his/her left forearm and left hand with a small, half-circular scab on top of his/her left hand.

During an interview, the resident said that two CNAs were getting him/her up with the Hoyer lift and while the CNAs were lowering him/her into the wheelchair, the bar of the Hoyer starting touching his/her left hand.

His/Her hands were on his/her sides and while staff placed his/her buttocks into the wheelchair, the bar pushed against his/her left hand, then pushed up onto his/her forearm causing bruising and a skin tear.

Observation on 2/25/26 at 10:55 A.M., showed CNA A and CNA B used a Hoyer lift to transfer the resident from his/her bed into his/her wheelchair.

There was not a third staff member involved in the transfer.

During an interview after the transfer, CNA A and CNA B said only two people were needed for the Hoyer transfer. CNA A and CNA B said they were not aware that the resident's care plan showed three people were needed during the resident's transfers.

During an interview on 02/26/26 at 3:09 P.M., the Interim DON and Current Administrator (CA) said if a resident obtained an injury during a staff-assisted transfer, they expected a nurse to do a head to toe assessment to evaluate the resident's skin.

They expected an incident report and progress note to be completed with a description of the injury.

They expected the physician, family/RR and DON to be notified and the notifications to be documented in the incident report/progress note.

Any new orders should be entered onto the resident's physician order summary and the nurse should enter an order on the resident's treatment administration record (TAR) to monitor the site until healed if no treatment is needed.

They expected staff to complete a progress note each shift for 72 hours after the incident.

They expected the post-incident progress note to include observations of the resident and if there were any changes to the injury.

They expected staff to follow the interventions listed in the resident's care plan.

They expected physician orders to be followed. 273784727378382786977

265343 02/26/2026

Country Villa Wellness & Rehabilitation 850 Country Manor Lane Creve Coeur, MO 63141

Review of the resident's progress note, dated 2/20/26 at 9:00 A.M., showed LPN E documented the resident had a seizure in the dining room, was taken to his/her room, placed into the bed, and given his/her seizure medications and a pain pill. No further seizure activity noted.

During an interview on 02/20/26 at 11:06 A.M., with the Interim Director of Nursing (DON) and the Previous Administrator (PA), they said they expected staff to be knowledgeable of and to follow facility policies.

They expected when medication was administered by a nurse or a CMT, they should document that it was administered by initialing on the resident's MAR. If there was no documentation, then it was not done/administered.

During an interview on 2/26/26 at 3:09 P.M., with the Interim DON and the Current Administrator (CA), they said they expected medication to be administered as ordered.

The Interim DON said the risk of not receiving seizure medication as ordered would increase the possibility of the resident having a seizure.

During an interview on 2/26/26 at 11:44 A.M., the resident's physician, Physician I, said the resident admitted to the facility over two years ago because he/she was having multiple uncontrolled seizures at home. He/She had been stable, until this month, which Physician I thought was due to missed seizure medications, because things were so messed up with the medication issue at the facility.

The resident told Physician I that he/she had five seizures back-to-back.

The DON notified Physician I about the resident's seizure activity on 2/20/26, but Physician I was not notified about the seizure activity on 2/16/26.

There have been times when residents were not getting their medications until 1:00 P.M.

The resident had missed one dose of a seizure medication about six or eight months ago and had an immediate seizure episode.

This is how Physician I knew the resident could not miss any seizure medications. 2743991