Lansdowne Village: Resident Left Soaked in Urine - MO
The resident told an inspector he had been waiting an hour. The room smelled of urine. When the inspector arrived, the call light wasn't even on anymore, suggesting it had timed out or been reset without anyone responding. The inspector asked the resident to press it again, at 5:31 a.m.
Eight minutes passed.
At 5:39, a certified nursing assistant finally entered the room carrying washcloths and a clean brief. When the CNA removed the soaked brief, it was saturated with urine. The CNA wiped the resident's groin and buttocks with wet washcloths and put on a clean brief. The resident said it felt better, after being soaked wet for a while.
The resident relied entirely on staff for all toileting needs. He could not get up and handle this himself. He could only wait.
The CNA, interviewed a few minutes later at 5:55 a.m., said he or she was responsible for roughly 20 residents during the night shift and would try to answer call lights within five minutes. Twenty residents, the CNA said, was manageable.
Whether 20 residents is manageable or not, this one had been waiting for more than an hour.
The complaint inspection that captured this moment was conducted on September 26, 2025, with the full survey completed November 17. The resident had told inspectors the problem was chronic, that being left wet happened more during evening and night shifts, that this always happened at night.
Four days after the early-morning observation, a licensed practical nurse identified in the report as LPN O told inspectors the facility had responded to concerns about incontinence care by holding in-service training a couple of weeks prior. Staff had a skills day, the LPN said. Direct care workers were required to demonstrate proper care techniques and were quizzed.
A quiz administered weeks before did not keep this resident dry at 5 a.m.
The Director of Nursing, interviewed the same day, described the standard clearly. Residents who are incontinent should be checked every two hours, the director said. If a resident is left wet too long, there is an increased risk of skin breakdown. And if a brief becomes saturated enough for the cotton to stick to the skin, if it soaks through to the bedding, that is too long.
The brief removed from this resident that morning was soaked. The inspection report does not say whether the bedding was also wet. It does not say how long the resident had actually been lying there before pressing the call light. It says the resident reported waiting an hour after pressing it, and that the odor of urine was present in the room when the inspector arrived.
The facility's own nursing director laid out the standard. The facility's own aide confirmed the overnight staffing ratio. The resident confirmed this was not a one-time failure.
CMS rated this deficiency at the level of minimal harm or potential for actual harm, affecting few residents. The citation falls under the requirement that facilities provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Lansdowne Village is located at 4624 Lansdowne Avenue in St. Louis.
The resident told the inspector it felt better, after the brief was changed. He had been waiting a long time for that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lansdowne Village from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
LANSDOWNE VILLAGE in SAINT LOUIS, MO was cited for violations during a health inspection on November 17, 2025.
The resident told an inspector he had been waiting an hour.
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.