Hillside Manor Healthcare And Rehab Center

F-F684 cited under Event ID 4F7E12

Based on observation, interview and record review, the facility failed to obtain physician orders and monitor a wound identified by staff for one resident (Resident #27). The census was 145.

Review of the Wound Management Policy, revised 10/24/22, showed:

-Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers;

-Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy. The diabetic ulcer characteristically occurs on the foot;

-Procedure: Assessment:

-A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;

-Upon identification of a wound the licensed nurse will:

-Measure the wound (length, width and depth);

-Initiate a wound monitoring record sheet:

-A wound monitoring record will be completed for each wound;

-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;

-An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to:

-Identifying risk factors;

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0684 -Treatment;

Level of Harm - Minimal harm or -Mechanical offloading and pressure reducing devices; potential for actual harm -Reducing skin friction, sheer, and moisture; Residents Affected - Few -Nutritional status;

-Evaluating and modifying interventions for a resident with an existing PU/PI;

-Wound Management:

-The attending physician will be notified to advise on appropriate treatment promptly;

-The licensed nurse will notify the responsible party of the presence of a pressure ulcer;

-Dietary contact will be made for nutritional assessment;

-Rehabilitation services will be contacted for appropriate devices or pressure redistributing devices;

-A licensed nurse will develop a care plan for the resident based on recommendations of dietary, rehabilitation and the attending physician;

-Per physician order, the nursing staff will initiate treatment and utilize interventions for pressure redistribution and wound management;

-The attending physician and interdisciplinary team (IDT) will be notified of:

-New pressure ulcers or wounds;

-Pressure ulcers or wounds that do not respond to treatment;

-Pressure ulcers or wounds that worsen or increase in size;

-Complaints of increased pain, discomfort or decrease in mobility by a resident;

-Signs of ulcer sepsis, presence of exudates (drainage), odor or necrosis (black, firm tissue), if not already noted by the physician;

-Residents refusing treatment;

-Certified Nurse Aides (CNAs) will complete body checks on resident's shower days and report unusual findings to the licensed nurse;

-Documentation:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0684 -New pressure ulcers or wounds will be documented on the 24 hour log and an incident report will be completed by the licensed nurse; Level of Harm - Minimal harm or potential for actual harm -Wound documentation will occur at a minimum of weekly until the wound is healed, documentation will include: Residents Affected - Few -Location of wound;

-Length, width, and depth measurements recorded in centimeters (cm);

-Direction and length of tunneling (a channel or tunnel that forms beneath the surface of a wound, extending into deeper tissue) or undermining (a separation of the wound edges from the underlying tissues, creating a space or pocket beneath the wound surface;

-Appearance of the wound base;

-Drainage amount and characteristics including color, consistency and odor;

-Appearance of wound edges;

-Description of the peri-wound condition or evaluation of the skin adjacent to the wound;

-Presence or absence of new epithelium at the wound rim;

-Presence of pain;

-IDT will document the discussions and recommendations for:

-Pressure ulcers and wounds that do not respond to treatment;

-Pressure ulcers and wounds that worsen or increase in size;

-Complaints of increased pain, discomfort or decrease in mobility by a resident;

-Signs of ulcer sepsis, presence on exudate, odor or necrosis;

-Residents refusing treatment;

-Licensed nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis;

-Document notifications following a change in the resident's skin condition;

-Update the resident's care plan as necessary.

Review of Resident #27's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/21/25, showed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0684 -Diagnoses of diabetes and peripheral vascular disease (PVD, poor circulation in the extremities), low blood pressure; Level of Harm - Minimal harm or potential for actual harm -No cognitive impairment;

Residents Affected - Few -Required moderate assistance of staff for personal hygiene;

-Required maximum assistance of staff for toileting, showering and dressing;

-No venous or arterial ulcers;

-No foot ulcers.

Review of the resident's care plan, updated 2/14/25, showed the following:

-Focus: Resident has PVD;

-Monitor, document, and report as needed any signs or symptoms of skin problems related to PVD: redness, edema, blistering, itching, burning, bruises, cuts, or other skin lesions.

Review of the resident's shower sheet, dated 3/7/25, showed no documentation of any wounds to the right heel.

Review of the facility's 24 hour shift report sheet, dated 3/8/25, showed a wound to the right heel.

Review of the resident's progress notes, dated 3/8/25 through 3/19/25, showed no documentation regarding

a wound to the right heel.

Review of the resident's physician's order sheet (POS), dated March 2025, showed no treatment order for

the resident's right heel.

Review of the resident's treatment administration record (TAR), dated March 2025, showed no treatment order for the resident's right heel.

Review of the resident's shower sheets, dated 3/10 and 3/13/25, showed no documentation regarding a wound to the right heel. The facility had no shower sheets for the week of 3/17 through 3/20/25.

Observation on 3/20/25 at 10:55 A.M., showed the resident lay in bed. The Director of Nurses (DON), Assistant Director of Nurses (ADON) and the facility's Wound Care Company's Nurse Practitioner (NP) assessed the resident's skin and noted a wound on the back of the resident's right foot just above the heel.

The Wound Care NP said the wound was a diabetic ulcer secondary to pressure that measured 0.6 centimeters (cm) by 0.6 cm by 0.3 cm depth, 90% granulation (new tissue) and 10% slough (soft dead tissue).

During an interview on 3/20/25 at 12:02 P.M., CNA W said he/she was unaware of the wound on the resident's right heel. He/She hadn't taken care of the resident before and had assisted another aide giving him/her a shower. He/she could not remember the name of the aide who she assisted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0684 During an interview on 3/20/25, at 1:26 PM., ADON W said he/she was unaware of the wound on the back of

the resident's heel. No one reported it to him/her nor did he/she see it on the 24 hour sheet. Staff are to Level of Harm - Minimal harm or document any changes in the progress note which can be generated on a summary sheet daily. He/She potential for actual harm expected staff to document any changes found in the progress note and obtain treatment orders.

Residents Affected - Few During an interview on 3/20/25 at 11:10 A.M., the DON said when staff find a wound, she expected the nurse to call the physician, get a treatment order, notify the DON and the wound company.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm 44950

Residents Affected - Few See

F-F686 cited under Event ID 4F7E12

Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14). The failure resulted in

the worsening of the identified sacral wound and the development of two additional pressure injuries. Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16). The census was 145.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 265585 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 265585 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm 44950

Residents Affected - Few See

F-F697 cited under Event ID 4F7E12

Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14). Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit. The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility. For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites. The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites. The sample was 16. The census was 145.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 265585