Pinnacle Point Wellness & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the health, safety, and welfare of Resident #1 was met when the facility provided the resident transportation to the bank and left him/her, returned but did not locate the resident and left without the resident. The resident did not receive his medications as ordered and slept outside in an alley. The resident borrowed a phone and called the facility to come pick him/her up the next morning. This affected one of seven sampled residents. The facility census was 114. On 06/29/26, the Administrator was notified of the past noncompliance which began on 06/17/26. Upon discovery, the facility administration immediately conducted an investigation, and corrective actions were implemented to include staff training regarding resident transportation. The noncompliance was corrected on 06/18/26. [...]

Inspectors wroteBased on interview and record review the facility failed to allow three residents (Resident #1, #2 and #3) to exercise their right to choose a physician, when the facility limited the choice of physicians to only those who were chosen by the facility, without allowing Residents #1, #2 and #3, to select their own physician. The facility census was 109. Review of the facility's Resident Rights policy, dated August 2020 showed:-All residents have a right to a dignified existence, self determination and communication with and access to persons and services inside and outside the facility; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect when staff allowed Resident #64 to scream and yell obscenities in the hall and dining room while Resident #41 sat in the dining room, and when staff failed to acknowledge Residents #22 and #33 when they rang their call light and asked for a snack. This affected three of 24 sampled residents. The facility census was 119. Review of the facility's Resident Rights policy dated, January 2023 showed:-Each resident had the right to a dignified existence, in an environment that promotes maintenance or enhancement of his/her quality of life;-Each resident had the right to self determination, which the facility must promote and facilitate through the support of resident choice;-The resident had the right to a comfortable and home like environment.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, when the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four residents (Resident #37, #5, #8, and #79) of the 24 sampled residents. The facility census was 119. Review of facility's Resident [NAME] of Rights policy, dated January 2023, showed: The facility residents have the right to be informed in advance of the risks and benefits of proposed care, of treatment alternatives or treatment options, and to choose the treatment option or alternative he or she prefers. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when facility staff failed to utilize appropriate personal protective equipment (PPE) for two Residents (Resident #13 and #112) of 24 sampled residents. The facility census was 119. Review of the facility's Management of Communicable Diseases policy, dated, September 2019, showed: -Standard precautions (a set of evidence-based infection control practices designed to prevent the transmission of infections in healthcare settings which includes: [...]

Inspectors wroteBased on record review and interview, the facility failed to to reimburse residents and/or their responsible parties within the 30 day time frame, after the residents were discharged from the facility, which affected eleven residents. The facility's census was 112. The facility did not provide a policy regarding conveyance of personal funds. Review of Interim Aged Analysis Summary, dated [DATE], showed: -Resident #215, discharged on [DATE], had a balance of $1,471.48; -Resident #219, discharged on [DATE], had a balance of $.09; -Resident #217, discharged on [DATE], had a balance of $3,296.00; -Resident #218, discharged on [DATE], had a balance of $1437.00; -Resident #220, discharged on [DATE], had a balance of $573.00; -Resident #221, discharged on [DATE], had a balance of $5450.00; -Resident #222, discharged on [DATE], had a balance of $2,351.26; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents received information and contact information for State and local advocacy organizations when the facility staff did not provide information to the residents on how to file a complaint with the State Survey Agency and did not prominently display this information in the facility for residents to view. The facility census was 112. Review of facility policy, Resident [NAME] of Rights, revised [DATE], showed facility residents shall have the right to receive from the facility a written description of legal rights including a list of names, addresses, (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies such as the State Survey Agency for information for filing grievances and complaints. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident representative was notified of a change in condition for two of the 23 residents sampled (Residents #102 and #86). The facility census was 112. Review of facility's Notification of Change In a Resident's Status Policy, dated 11/2017, showed: -The attending physician/physician extender and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations; -Responsibility: all licensed nursing personnel; -Guideline for notification of physician and responsible party (not all inclusive): a) Onset of pressure sores; b) Any accident or incident; -Documentation of notification of responsible party in the Interdisciplinary Team Notes. 1. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure a clean, comfortable, and homelike environment and comfortable sound levels. Additionally, the facility failed to ensure resident wheelchairs were clean and maintained in good repair. This affected six sampled residents (Resident #26, #29, #48, #83, #21, and #315) out of 23 sampled residents. The facility census was 112. Review of the facility policy, Resident Rights, dated 1/2023, showed residents have the right to a clean and homelike environment. The facility did not provide a policy on maintaining resident medical equipment. Review of the facility policy, Resident Room Cleaning, dated 6/2018, showed: -Spot clean walls; - Remove trash. 1. Review of Resident #29's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/11/25, showed: -Cognition severely impaired; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to provide complete perineal care for Resident #165 after an incontinence episode. In addition, the facility failed ensure call lights were answered timely for four residents (Resident #3, #10, #34, and #35). This affected five of 23 sampled residents The facility census was 112. Review of the facility policy, Resident [NAME] of Rights, dated 1/2023, showed: -Receive services in the facility with reasonable accommodation of resident needs and preferences; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff failed to clean and disinfect a resident's mattress and seated rolling walker after being soiled with urine and feces, which affected one of the 23 sampled residents, (Resident #165), failed to use and failed to use personal protective equipment (PPE, equipment worn to minimize exposure to a variety of hazards, examples included gloves, gowns and masks) for residents who were on Isolation for Contact requirements or Enhanced Barrier Precautions (EBP, infection control measures that go beyond standard precautions and focus on reducing the transmission of multidrug-resistant organisms (MDROs), for Resident #1 and #103. The facility census was 112. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner to maintain their dignity when staff failed to knock on a resident's door and wait for a response before entering which affected four of 23 sampled residents, (Resident #1, #30, #104, and #165) and additionally when staff opened Resident #1's door exposing the resident's bare skin from the waist down, in view of the hallway. The facility also failed to shower one resident (Resident #32) per his/her preference. The facility census was 112. Review of the facility's policy titled, Resident [NAME] of Rights, revised 1/23, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate and timely update of assessments when one resident's (Resident #48) change in functional abilities and use of a wheelchair, was not updated with a significant change and when one resident (Resident #86) had a change in cognitive status from cognition intact to cognition severely impaired on the Minimum Data Set (MDS) ( a federally mandated assessment completed by facility staff). This occurred for two of twenty-three sampled residents (Resident #48 and #86). The facility census was 112. The facility did not provide a policy regarding updating the MDS when residents have a change of condition. 1. Review of Resident #48's, Significant change MDS, dated [DATE], showed: -Cognition severely impaired. -Hospice care added, which was not on prior MDS; -He/She was dependent on a walker; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs (Resident #74), resident's shaving preferences (Resident #25), and resident's change in mobility status and need for feeding assistance (Resident #48) which affected three (Resident #74, #25, and #48) of 23 sampled residents. The facility census was 112. Review of facility policy, comprehensive person-centered care plans, dated 1/2025, showed: -Each resident would have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that would identify how the interdisciplinary team would provide care. -Care plan could be revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change, and annual assessments per the RAI manual; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals in place for three residents (Resident #29, #83, and #79) of the 23 samples residents. The facility census was 112. Review of the facility policy, Resident [NAME] of Rights, dated January 2023, showed the facility shall provide a safe environment. Facility did not provide a policy on regarding accident prevention. Review of facility policy, Accident and incident documentation and investigation, dated July 2018, showed: -Accidents and/or incidents involving resident care will be investigated and documented on there resident incident report entry form in the long term care system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made two errors out of 25 opportunities for error, which resulted in an error rate of 8%. This affected one of the 23 sampled residents, (Resident #72). The facility census was 112. Review of the facility's policy titled, Medication administration-general guidelines, revised 8/16, showed: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when eye drops (Resident #26) and one blue pill (Resident #27) were left at bedside. This affected two out of 23 sampled residents. The facility census was 112. Review of facility policy, Medication Administration General Guidelines, revised August 2016, showed: - Residents are allowed to self-administer medications when specifically authorized by the attending physician and the interdisciplinary team and in accordance with procedures for self-administration of medications; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide acceptable accommodations for one non English speaking resident (Resident #104) and failed to provide one resident appropriate seating for meal times when his/her chair put his/her at face at table height (Resident # 26). This affected two of 21 sampled residents. The facility census was 103. Facility did not provide a policy on accommodation of needs. Review of Resident [NAME] of Rights, revised 1/23, showed: -Each resident had a right to dignified existence, self-determination, and communication with and access to persons and services and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123, to Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay. This affected two out of 21 sampled residents (Resident #1 and #93). The facility census was 103. The facility did not provide the requested policy for Notice of Medicare Non-Coverage (NOMNC) form CMS - 10123. CMS Guidlines: Form CMS-10123, is given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending. The NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization. 1. Review of Resident #1's medical record showed: [...]

Inspectors wrote4. Review of Resident #77's Quarterly Minimum Data Set (MDS), completed by facility staff and dated 8/9/24, showed: - Cognitive skills intact; - Independent with transfers; - Diagnoses included anxiety and depression. Review of the resident care plan, dated 4/4/2022, showed: - The resident had an alteration in sleep pattern related to insomnia ( persistent problems falling and staying asleep); administer medications as ordered by the physician; observe for changes in sleep pattern inability to fall/stay asleep; provide a quiet restful environment. During an interview on 10/7/24 at 3:17 P.M., the resident said; - The staff take the smoking cart outside and roll it past his/her door and it is very loud; - There is something broken on it and it makes a loud clunking sound; - The smoking cart has been broken for over a month; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from physical restraints when the facility failed to obtain a physician's order, assess, monitor or care plan the use of a seat belt (a belt or strap used to secure a person to prevent injury) for one resident (Resident #11) and when the facility staff failed to unlock the wheels of a wheelchair for one resident (Resident #84) after the resident was observed pushing against the table with his/her hands, pushing back into the back of the wheelchair and yelling out repeatedly, He/She didn't want it. The facility census was 103. Review of the facility's Restraint Evaluation and Reduction policy, dated December 2023, showed in part: -All residents have the right to be free from restraints; [...]

Inspectors wroteBased on record review and interview, the facility failed to check the Family Care Safety Registry (FCSR, a registry that provides background information on people who work with children, seniors, and people with disabilities in Missouri) for three of the 10 sampled employees prior to them having contact with any resident. The facility census was 103. Review of the facilty's Abuse Prevention Policy, dated October 2022, showed in part: -The facilty is committed to protecting the residents from abuse; -The facilty conducts employee back ground checks; -The facilty will pre -screen all potential employees for a history of abusive behavior. 1. Review of Dietary Aide E's personnel file showed: -Date of hire 9/17/24; -A check of the FCSR dated 10/9/24; -The facilty failed to check the FCSR before the employee had contact with the residents. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure resident Minimum Data Set (MDS: a federally mandated Assessment tool completed by facility staff) assessments were completed accurately and timely for four of 21 sampled residents (Residents #72, #33, #84 and #39). The census was 103. Review of the facility provided policy, MDS Assessments dated 6/2023 showed: -The facility shall conduct interdisciplinary assessments using the MDS item sets. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care as a means by which the facility can track changes in a resident's status. -Non-Medicare covered residents will be completed upon admission, discharge, quarterly and annually per Federal/State requirements. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan for four of 21 sampled residents (Residents #39, #113, #26, #84) by not addressing care areas of resident side rail usage (Resident #39 and #113), use of a bilevel positive airway pressure device (bipap) (a noninvasive ventilator that helps people breathe by delivering pressurized air into airways) (Resident #39), and significant weight loss (Resident #26 and #84). The facility census was 103. Review of facility policy, comprehensive person centered care plans, revised March 2018, showed: -Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal care at least every two hours. This affected two of the 21 sampled residents, (Resident #11 and #19). The facility census was 103. Review of the Missouri Resident [NAME] of Rights, provided through the state long term are ombudsman (a person who represents the interests of residents) program included Residents have the right to privacy, to be treated with consideration, respect, and dignity, recognizing each resident' s individuality. Review of the facility's Incontinent Care Policy, review date January 2015, showed -Provide routine, preventative skin, perineal care after each incontinent episode. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat significant weight loss for two residents (Resident #26 and #84) and failed to provide adequate hydration for 6 residents (Resident #26, #84, #35, #57, #94 and #4) of the 21 sampled residents. The facility census was 103. Review of the facility provided policy Hydration Cart dated 2016 showed: -Water or other fluids shall be offered to all residents throughout the day. Fluids are typically offered during meals, snacks. A hydration cart or location may be used to enhance access and encouragement of fluids for residents. -The Hydration Cart will be offered or refreshed each day at mid morning, mid afternoon and bedtime. -The cart or location will include fresh ice water and another beverage such as iced tea or lemonade. And may include snacks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight, and failed to obtain physician's orders for side rails for four of 21 sampled residents (Resident #39, #113, #54, and #104). The facility census was 103. The facility did not provide a policy on entrapment. 1. Review of Resident #39's quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/13/24, showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood and understand others; -He/She was dependent on his/her wheelchair for mobility; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 26 opportunities for error, resulting in a medication error rate of 20%. This affected five of the 21 sampled residents, (Resident #4, #15, #43, #91 and #103). The facility census was 103. Review of the facility's policy for general guidelines for medication administration, dated 8/16, showed, in part: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide food that was palatable and attractive when hall trays were not served per resident food preferences and was not attractive. The deficient practice affected two of 21 sampled residents (Resident #85 and #52 ). The facility census was 103. The facility did not provide a policy for resident food preferences. 1. Review of Resident #85's Quarterly MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She required set up or clean up assistance with eating; -Diagnoses included: cancerous tumor, dementia, and anxiety. Review of care plan, undated, showed: -He/She was able to feed self but had dementia that may affect food intake and his/her weight; -Obtain/update food preferences; -Serve diet as ordered. Review of physician's orders, dated October 2024, showed: -Ordered 6/10/24, He/She was on a regular diet. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the walls, ceilings, and floors, of the facility were maintained in good repair. This had the potential to affect all residents. The census was 103. The facility did not provide a policy on upkeep and repair. 1. Observations beginning on 10/08/24 at 7:58 A.M. on the Special Care Unit (SCU) showed: -Hallway light fixtures had dead bugs, dust and debris; -Hallway hand rails were scratched and had scuff marks; -The Utility room door had large scratches and chipped paint; -room [ROOM NUMBER] entry door was scratched with large areas of chipped paint and drug against the floor when opening/closing; -room [ROOM NUMBER] entry door had chipped paint that exposed the wood underneath; -room [ROOM NUMBER] entry door was scratched with chipped paint; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an effective pest control program to prevent gnats, flies and wasps in resident rooms, dining rooms, and hallways. The facility census was 103. The facility did not provide a pest control policy. 1. Observation on 10/07/24 at 9:18 AM showed multiple gnats in room [ROOM NUMBER]. 2. Observation on 10/07/24 at 11:05 A.M. showed multiple flies in the dining room. 3. Observation on 10/07/24 11:21 AM showed room [ROOM NUMBER]: -A fly strip hanging from the room divider with multiple dead flies on it; -Multiple flies and gnats in the room. 4. Observation on 10/07/24 at 11:30 AM Resident #18 said -There were flies in his/her room a lot; -There were multiple flies in room, landing on resident and crawling on the bed. 5. Observation on 10/08/24 at 7:58 A.M. on the Special Care Unit showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were cared for in a dignified way when staff tugged on a residents shirt, ignoring the residents repeated requests for them to stop. Furthermore, staff treated the resident disrespectfully by yelling at the resident when the resident attempted to self propel his/her wheelchair up and down the halls of a secured care unit. This affected one of 21 sampled residents (Resident #85). The facility census was 103 Review of the facility provided Resident [NAME] of Rights dated 01/2023 showed: [...]

Inspectors wroteBased on interviews and record review, the facility failed to assist one resident of the 21 sampled residents (Resident #82) with help in obtaining a hearing aide. The facility census was 103. Review of the facility's job description for the director of social services, dated 8/1/2012, showed, in part: - Under the direction of the Executive Director, the Social Services Director is responsible for monitoring the residents' mental and psycho-social needs and to provide the services to meet these needs in order to attain or maintain the highest practicable level of physical, mental, and psycho-social well-being; - Utilizes the Resident Assessment Instrument (RAI) process in conducting a psycho-social assessment; - Formulates a care plan which addresses the identified problems, needs, and concerns; - Documents progress toward goals, assessment updates, and interventions; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to provide a meal to a resident within 15 minutes after receiving fast acting insulin. This affected one out of 21 sampled residents, (Resident #103). The facility census was 103. Review of the facility's policy for general guidelines for medication administration, dated 8/16, showed, in part: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only be persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication; [...]

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure prescribed medications were administered at the prescribed time and were available for administration for eight of 13 residents (Resident (R)95, R62, R24, R41, R54, R263, R17, and R48) in the medication administration observation. These failures caused 29 medication errors out of 59 opportunities for error, or a medication error rate of 49.15%. The facility census was 115.

Inspectors wroteBased on interview and record review, the facility failed to maintain a qualified administrator on duty from 2/15/2024 to 3/3/2024. The facility census was 106. During an interview on 2/14/24 at approximately 4:00 P. M., Administrator B notified the state survey agency that he/she was no longer the Administrator of record at the facility. Review of the current Missouri Board of Nursing Home Administrators (MBNHA) license registry website showed Administrator A not listed as a current Missouri Licensed Administrator. During an interview on 2/27/2024 at 11:50 A.M., Administrator A said: -He/She had completed the Administrator in Training program, but has not taken the test to obtain an administrator license. -He/She thought the State regulations state the new administrator had 120 days to obtain an administrator license. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to evaluate and respond to a change in condition for two residents (Resident #152, and #72) when the facility failed to recognize one resident (Resident #152) was lethargic, difficult to arouse, and had minimal to no oral intake for over 24 hours which resulted in an emergency discharge to the hospital for severe dehydration, urinary tract infection and possible sepsis (a life threatening result of infection that could lead to tissue damage, organ failure and death). The facility staff also failed to identify and respond to one resident (Resident #72) who had a critically high blood glucose reading following blood glucose readings consistently over 200 milimoles per liter (mmol/l : [...]

Inspectors wroteThis deficiency is uncorrected. For previous examples, see the Statement of Deficiencies dated 11/20/23. Based on observation, interview, and record review, the facility failed to ensure four (Resident #21, #57, #80, #7) of six sampled residents who required staff assistance received the necessary assistance with bathing. The facility census was 109. Review of facility policy, Bath/Shower-Dependent, dated 9/03, showed a bath for cleanliness and comfort is scheduled at least weekly for each resident. 1. Review of Resident #21's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/5/23, showed: - A Brief Interview Mental Status (BIMS) an assessment used in long term care facilities to monitor cognition) of 15, which indicated he/she had intact cognition; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the call light system was accessible and functioned properly for two of 22 sampled residents who required staff assistance (Resident #19 and #57). The facility census was 106. The facility did not provide a policy regarding call lights. 1. Review of Resident #57's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/31/23, showed: - No Brief Interview of Mental Status (BIMS); - No recorded resident preferences; - Substantial/Maximal assistance for toileting hygiene, showering upper and lower body dressing, rolling left and right, and sitting to lying; - The resident was always incontinent of bowel and bladder; - Diagnoses of Hypertension (HTN), heart failure, diabetes, severe obesity, and a burn of second degree to the abdominal wall. [...]