Hillside Health Care Center

During an interview on 4/23/26 at 12:33 P.M., Licensed Practical Nurse (LPN) E said Resident #133 and Resident #139 wanted to keep Physician RR.

There was a third resident that loved Physician RR.

They met the new physician, but they had a rapport with Physician RR. 6.

During an interview on 4/24/26 at 10:16 A.M., the DON said there were no residents that expressed feelings about not having Physician RR anymore.

Physician RR was difficult to get ahold of and get in contact with. It was easier to talk to Nurse Practitioner SS. 7.

During an interview on 4/24/26 at 3:38 P.M., the Administrator said the residents received 30 days' notices that the primary physician was changed.

Residents were able to continue to see Physician RR, but not in the facility.

They had to go to Physician RR's office.

She would expect the residents to choose their own physician and they could choose to see Physician RR, but outside the facility.

The only resident that wanted to continue to see Physician RR was Resident #133. He/he was given the option to see Physician RR, just not at the facility.

Intake: 2797362

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

During an interview on 4/24/26 at 10:39 A.M., Maintenance Worker FF said housekeeping was responsible for the soap and paper towel holders.

The residents ripped them off the wall.

The front desk had a plan to keep them stocked. 5.

Observations on 4/19/26 at 9:48 A.M., 4/20/2026 7:47 A.M., and 4/24/26 at 10:39 A.M., showed room [ROOM NUMBER] had four tiles removed, visible from the doorway and another tile removed from in front of the bed.

The removed tiles were laid out on the floor. A television was on the floor next to the window with a cord in the walkway. 6.

During an interview on 4/24/26 at 10:58 A.M., the Maintenance Director said the tiles removed and left on the floor in room [ROOM NUMBER] did not make it a homelike environment. He needed some adhesive glue to put the tiles back on the floor.

He was not informed or saw a work order for the soap dispenser or paper towel holder removed in the first shower room. He was unaware the second shower room had holes in the wall where the toilet paper holder used to be.

During an interview on 4/10/26 at 12:32 P.M., the Administrator said maintenance was responsible for fixing things that were broken.

Housekeeping staff was responsible for cleaning the facility.

The Administrator said she expected the removed tiles to be picked up off the floor and removed from residents' area.

Loose tiles could cause other residents to trip or other residents to throw them.

She expected the broken paper towel holder and soap dispenser to be fixed.

The second shower room with the toilet paper holder missing should have been fixed, and the holes patched. 2983889

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

During our investigation and getting statements,

This was unwitnessed.

Assessments completed, family, and physician notified. Resident #1 sent to the hospital. X-rays for Resident #49 ordered and awaiting results;-Conclusion/outcome for investigation: Resident #1 was the aggressor and hit both residents unprovoked. It is noted that Resident #1 has a UTI and is on antibiotics for it;-Care plan changes and interventions: Care plan updated, room changes when Resident #1 returns to the facility;-Was there a physical altercation: Yes;-Has the resident had any ongoing concerns: Yes;-Steps taken to prevent further occurrence of the issue: Room/unit moves;-In conclusion of this investigation, it is reasonable to believe that this injury was not caused by abuse or neglect and was not preventable and is not previous ongoing problem that the facility could have foreseen due to prior history: Yes.

Review of CNA X's interview from the facility's investigation, undated, showed CNA X said he/she helped his/her co-worker stop Resident #1 from jumping on Resident #111. As they were escorting Resident #1 down the hall, Resident #49 hit him/her in the head. Resident #49 told Resident #1 he/she was going to get him/her when he/she comes back in the room that night.

Review of Resident #1's witness interview, dated 4/18/26, showed Resident #1 said Resident #111 got off the elevator and went past Resident #1 and Resident #1 swung on Resident #111 for no reason at all, hitting him/her in the head.

Resident witness screamed for help and the aides came and stood in between them separating them.

They escorted Resident #1 to 1 South nurse's station to watch him/her.

While taking Resident #1 to the nurse's station, Resident #49 was rolling by and Resident #1 started hitting Resident #49 as he/she rolled by. 3.

During an interview on 4/22/26 at 5:41 P.M., Licensed Practical Nurse (LPN) E said Resident #1 was originally placed on the 3rd floor locked unit for behaviors. He/She was moved to the 1st floor, where he/she was pleasant. On 4/9/26, a UA was ordered because the resident was not acting normally.

Then, he/she was fighting. He/She had a systemic UTI, which was affecting him/her.

Staff sent him/her out to the hospital.

The resident returned to the facility today at 5:00 P.M. and already attacked LPN E. LPN E attempted to remove the resident's bandage to complete a skin assessment and the resident scratched LPN E.

During an interview on 4/23/26 at 2:50 P.M., LPN BB said Resident #1 was being different. He/She was on antibiotics for UTI when he/she went to the hospital.

After the resident returned to the facility, he/she was placed on increased monitoring.

During an interview on 4/24/26 at 10:16 A.M., the Director of Nurses (DON) said if there was an altercation, there would be monitoring of the resident for 72 hours.

She would have to check the policy, but this monitoring is a nursing standard.

During an interview on 4/24/26 at 3:38 P.M., the Administrator said she expected residents to be free from abuse and for staff to follow the facility's Abuse and Neglect policy. If a resident displayed a change in behavior or had an increase in behaviors, she would expect staff to continue to monitor the resident and document it in the medical record.

Following the physical altercations, the resident was supposed to be on increased monitoring from staff. 298380229875162987523

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Review of the physician's progress dated 04/7/26, showed encourage PT evaluation for mobility and knee rehabilitation for management of shoulder pain.

Review of the ePOS showed no current order for PT evaluation.

Review of the nurse's progress notes showed no documentation for PT evaluation. 4.

During an interview on 04/24/26 at 3:41 P.M., the DON said she expected staff to follow policy and procedures set by the facility.

She said the ADON and DON were responsible to audit physician's orders.

She would expect staff to notify the doctor of any new changes or orders from referral physicians. 1619729

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Review of the resident's electronic medical

more shirts, pants and socks.

Staff to follow up;-No documentation of resident refusals to receive

11:01 A.M., showed the resident with messy hair and dressed in a stained white shirt and jeans.

The resident's fingernails long and yellow.

During an interview on 4/19/26 at 11:01 A.M., the resident said his/her fingernails needed to be cut.

Observation on 4/20/26 at 7:55 A.M., showed the resident wore the same stained white t-shirt and jeans from 4/19/26.

Observation on 4/21/26 at 7:39 A.M., showed the resident in the same stained white-t-shirt and jeans from 4/19/26.

During an interview on 4/21/26 at 8:42 A.M., the resident said he/she wanted his/her clothes changed.

Observation on 4/22/26 at 11:58 A.M., showed the resident in the same stained white t-shirt and jeans from 4/19/26.

During an interview on 4/23/26 at 8:24 A.M., CNA AA said most of the residents do not have clothes.

Now that the elevators are down the laundry personnel have not brought the clothes to the floors. At this time, the resident does not have clothes.

During an interview on 4/23/2026 at 8:24 at A.M., CNA L said he/she believed the resident was scheduled for showers on the evening shift.

During the interview, CNA L checked the shower book at the nurse's station and noted the resident was scheduled for showers on Wednesday and Saturdays. 3.

Review of Resident #110's quarterly MDS, dated [DATE], showed:-Diagnoses included diabetes, muscle weakness, chronic kidney disease, dementia, depression, heart failure, and reduced mobility;-Supervision required during meals;-Severe cognitive impairment.

Review of the resident's care plan, in use at the time of the survey, showed:-Problem: The resident has an ADL self-care performance deficit;-Desired outcome: The resident will maintain current level of function in ADLs through the review date;-Interventions: Supervision while eating.

Observation on 4/19/26 at 1:08 P.M., showed the resident in bed.

His/Her bedside table to the right of the bed out of reach of the resident. A tray of untouched food on the bedside table.

Observations of the resident on 4/20/26, showed:-At 7:48 A.M., the resident in bed. He/She attempted to grab his/her drink off the bedside table positioned to the right of the bed. He/She was unable to reach the drink.

The resident's privacy curtain pulled and the room door closed;-At 8:44 A.M., the resident in bed. A plate of breakfast on his/her lap.

His/Her side table with his/her drinks positioned to the right of the bed, out of reach of the resident.

The privacy curtain pulled and the room door closed.

During an interview on 4/24/26 at 6:55 A.M., CNA L said the resident sometimes needed encouragement from staff to come to the dining room to eat. He/She preferred to eat in his/her room. CNA L expected staff to supervise the resident during mealtimes.

During an interview on 4/24/26 at 4:13 P.M., the Administrator and DON said staff should supervise the resident during meals, if indicated on the resident's care plan and MDS.

They expected staff to ensure bedside tables, food, and drinks were in reach of residents. 298757029832672990492

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Observation on 4/20/26 at 7:55 A.M. and 4/22/26 at approximately 3:00 P.M., showed the resident did not have dressing to his/her right foot second toe.

The second toe nail bed was scabbed over with no drainage.

The resident said a staff member was removing his/her bed sheet and his/her toenail got caught and pulled the toenail off.

The resident said that the staff was only dressing the toe for the first couple of days after the incident happened and then the nurse decided to leave the toe wound open to air.

During an interview on 4/24/26 at 12:10 P.M., LPN BB said the resident had current treatment orders for his/her right foot, second toe.

The last few days LPN BB had been leaving the dressing open to air. LPN BB didn't think she was signing off the dressing change was completed but wasn't sure.

All nurses were responsible for completing and documenting the wound treatments.

During an interview on 4/22/26 at 9:32 A.M., the DON was not made aware of the incident with the resident's toe on his/her right foot.

Staff was expected to inform her of any new skin issues because she was also the Wound Nurse.

She would expect staff to reach out to her regarding adding or discontinuing treatments. 5.

During an interview on 4/24/26 at 3:41P.M., the DON said she would expect staff to follow the physician orders and document the wound treatments only when completed. If a wound treatment is changed for any reason, there should be new orders placed in the electronic medical record (EMR).

Intake: 2987516

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

During an interview on 04/23/26 at 9:26 A.M., Care

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

During an interview on 04/20/26 at approximately 12:00 P.M., the Social Service Director said she did not know the resident well and had only been working at the facility for about one month.

During an interview on 04/20/26 at 12:33 P.M., Wound Nurse NN said it was reported that the resident always was chewing his/her right hand dressing off.

The resident was admitted without an index finger to his/her right hand.

The resident was frequently left alone in his/her room when he/she visited the resident.

Wound Nurse NN was not aware of any special intervention for staff to monitor the resident.

The resident was always heard yelling and cursing from his/her room.

During an interview on 04/20/26 at 2:45 P.M., CNA JJ said the resident could raise his/her arms and chew on the dressings that were on the right hand.

The resident had frequent outbursts.

The resident would get mad if there were no cheese on his/her eggs, and he/she would strike his/her head with his/ her arms and start cursing at the staff.

Everyone knew about the resident's behavior. CNA JJ would have the resident sit in the hall near the nurses' station. If CNA JJ saw the resident bite his/her hand or try to hit him/herself in the head, CNA JJ would try to intervene and stop the resident.

There were no special interventions in place for the resident's self-mutilation.

The resident was not on 1:1 or frequent checks.

During an interview on 04/21/26 at 5:25 A.M., LPN I said he/she was aware the resident had bit his/her fingers previously.

Nursing staff should document all behaviors that the residents have, and notify the psychiatrist and primary physician of ongoing behaviors. LPN I was aware he/she did not have very good documentation of the resident's behaviors.

The resident needed stronger medication to stabilize his/her moods. LPN I did not reach out to the psychiatrist when the resident had his/her outbursts because the resident was always difficult to deal with, and his/her behaviors were nothing new.

During an interview on 04/22/26 at 11:42 A.M. the Social Service Designee said when the resident was first admitted to the facility, not much was known about him/her.

After a couple of weeks, they had to send him/her out because he/she was nibbling on his/her fingers.

When he/she came back, the finger was wrapped.

The resident does not like to talk to people.

She did not know what the residents' [TRUNCATED]

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/26, showed:-Diagnoses included type two diabetes;-Cognitively intact.

During an interview on 4/20/26 at 7:27 A.M., the resident said the food tasted terrible and was always cold. 2.

Review of Resident #5's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic kidney disease;-Moderately impaired cognition.

During an interview on 4/19/26 at 10:43 A.M., the resident said food was most always cold when it was delivered to him/her. 3.

Review of Resident #12's quarterly MDS, dated [DATE], showed:-Diagnoses included anorexia (eating disorder);-Cognitively intact.

During an interview on 4/19/26 at 9:22 A.M., the resident said the food was most always served cold. He/She said he/she had an eating disorder, and it did not help that the food was cold, which made him/her not want to eat it. 4.

Review of Resident #78's quarterly MDS, dated [DATE], showed:-Cognitively intact.

During an interview on 4/19/26 at 8:57 A.M., the resident said the food was served cold a lot of the time. 5.

Review of Resident #148's quarterly MDS, dated [DATE], showed:-Moderately impaired cognition.

During an interview on 4/20/26 at 8:48 A.M., the resident said the food could sometimes be cold. 6.

Observation on 4/19/26 at 9:01 A.M., of the 300 south hallway breakfast, showed:-Breakfast was served in Styrofoam boxes;-Sauage patty measured 81.5 degrees Fahrenheit (F) and was cold;-Scrambled eggs measured 80.7 degrees F and were cold;-Cream of wheat measured 118 degrees F and was cold.

Observation on 4/20/26 at 12:01 P.M., of the 200 hallway lunch, showed:-The room tray cart was uncovered and the plates had no coverings;-Pasta with meat measured 120 degrees F and was lukewarm;-Mixed veggies measured 108 degrees F and were cold. 7.

During an interview on 4/24/26 at 7:29 A.M., the Regional Certified Dietary Manager said he would expect food to be delivered to residents at a safe and palatable temperature. He would expect staff to return food to the kitchen if it was too cold. 8.

During an interview on 4/24/26 at 10:32 A.M., [NAME] O said the facility policy was to deliver food to the residents at a safe and palatable temperature to avoid sickness. 9.

During an interview on 4/24/26 at 10:45 A.M., the Administrator said she would expect food to be delivered to residents at a safe and palatable temperature. 28058152978916

265585 04/24/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

During an interview on 4/24/26 at 4:20 P.M.,

and the Maintenance Director if they were seeing mice or mouse droppings.

She would expect staff to