Hillside Health Care Center: Wound Care Falsified - MO
The resident told inspectors that staff dressed the wound for only the first couple of days. Then, the resident said, a nurse decided to leave the toe open to air. Standing orders from the physician said otherwise: clean the wound daily, apply wound gel, cover with an ABD pad, wrap with Coban. Those orders had been in place since April 2, 2026, and the treatment record showed the dressing completed every single day through April 24.
Inspectors observed the resident on April 20 at 7:55 in the morning and again on April 22 at roughly 3:00 in the afternoon. Both times, the right foot had no dressing. The second toe nailbed was scabbed, open.
LPN BB confirmed it. She told inspectors she had been leaving the dressing open to air for the last few days. As for whether she had been signing off that the treatment was completed during that time, she said she didn't think so, but wasn't sure.
The Director of Nursing, who also served as the facility's wound nurse, said on April 22 that she had never been told about the incident at all. She said she expected staff to notify her of any new skin issues and to contact her before changing or stopping any wound treatment. No one had.
Two days later, she told inspectors she would expect staff to follow physician orders and document treatments only when actually completed. Any change to a wound treatment, she said, requires a new order entered into the electronic medical record. No new order had been placed.
The inspection, a complaint survey completed April 24, 2026, classified the violation as causing actual harm. The resident, whose toenail was pulled off by a bed sheet, spent weeks with an open wound on their foot while paperwork recorded that someone was taking care of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillside Health Care Center from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
HILLSIDE HEALTH CARE CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on April 24, 2026.
The resident told inspectors that staff dressed the wound for only the first couple of days.
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.