Hillside Health Care Center: Resident Attack Violations - MO
The resident who threw that first punch, identified in inspection records as Resident #1, had been moved to the first floor after a stint on a locked third-floor unit specifically designed for residents with behavioral problems. Staff described him as pleasant after the move. Then, in early April, he started acting differently. A urine analysis was ordered on April 9. The results came back showing a systemic urinary tract infection. He was fighting. He was sent to the hospital.
He came back on April 22 at 5:00 in the evening.
Within hours of his return, he scratched Licensed Practical Nurse E while she was trying to remove his bandage to check his skin. LPN E described it herself during an interview with inspectors on April 22 at 5:41 p.m. She had been trying to complete a routine skin assessment. He attacked her.
The attack on LPN E was not the first time that day she had reason to be concerned. Before the hospital stay, Resident #1 had already injured two other residents in separate incidents that unfolded in rapid, chaotic sequence.
According to a witness interview dated April 18, Resident #1 was in a hallway when Resident #111 stepped off an elevator and walked past him. Resident #1 swung on Resident #111 without provocation, hitting him in the head. A resident who witnessed it screamed for help. Aides came and stood between them, separating the two, and began walking Resident #1 toward the first-floor nurse's station to keep watch over him.
They never made it without incident.
While being escorted down the hall, Resident #1 passed Resident #49, who was rolling by in a wheelchair. Resident #1 started hitting Resident #49 as he rolled past. CNA X, whose interview was included in the facility's own investigation records, described the scene differently but consistently: he or she had helped a co-worker stop Resident #1 from jumping on Resident #111, and while they were walking Resident #1 down the hall, Resident #49 hit Resident #1 in the head. Resident #49 told Resident #1 he was going to get him when he came back to the room that night.
The facility's internal investigation concluded that Resident #1 was the aggressor in both incidents and that neither attack was provoked. Assessments were completed. Family was notified. Physicians were notified. Resident #1 was sent to the hospital. X-rays were ordered for Resident #49, whose hand had been struck with a wheelchair pedal, and the facility was still awaiting those results when inspectors arrived.
The facility's own investigation summary noted that Resident #1 had a UTI and was on antibiotics. It concluded the incidents were not caused by abuse or neglect, were not preventable, and were not part of an ongoing problem the facility could have foreseen. Inspectors were not persuaded by that framing. The inspection report documents actual harm to residents.
What the records show is a resident with a documented history of behavioral problems severe enough to require placement on a locked unit, who was later moved to general population, who began showing behavioral changes in early April, who was diagnosed with a systemic infection known to cause confusion and aggression in elderly patients, who attacked two residents in one day, was hospitalized, returned, and attacked a nurse the same evening he walked back through the door.
The Director of Nurses told inspectors on April 24 that after any altercation, the facility's practice was to monitor the involved resident for 72 hours. She said she would have to check the policy, but described it as a nursing standard. The Administrator, interviewed the same afternoon, said she expected staff to monitor residents who displayed behavioral changes and to document that monitoring in the medical record. She said that following the physical altercations, Resident #1 was supposed to be on increased monitoring.
Supposed to be.
LPN BB, interviewed on April 23, said that after Resident #1 returned from the hospital, he was placed on increased monitoring. But LPN E's account of being scratched during a skin assessment on the evening of his return raises an immediate question: where was that monitoring when a nurse was alone with a resident who had just been hospitalized for violent, infection-driven behavior and had not yet been stabilized?
The inspection report does not answer that question directly. It does not say who was assigned to watch Resident #1 when he returned, or whether anyone checked his behavior before LPN E walked in to do her assessment. What it says is that the Administrator herself acknowledged the monitoring was supposed to happen, and that inspectors found the deficiency worth citing as actual harm.
LPN E described Resident #1's trajectory with clinical plainness during her interview. He was originally on the locked unit for behaviors. He moved to the first floor and was pleasant. A UTI changed him. He was fighting. He went to the hospital. He came back and attacked her.
That sequence, laid out by a nurse who works there, is a description of a system that responded to each individual event without ever getting ahead of the pattern. The UTI was identified. The hospital stay happened. The return to the facility happened. The increased monitoring was ordered. And still, within hours, a nurse was scratched during a routine assessment.
LPN BB said Resident #1 was being different when the behaviors began. Different is the word a nurse uses when something has shifted but the paperwork hasn't caught up yet. By the time the paperwork did catch up, two residents had been struck and a nurse had been scratched.
The facility's plan following the incidents included updating the care plan and moving Resident #1 to a different room or unit when he returned. Room changes are a logistical response. They address where a resident sleeps, not what happens in a hallway when someone steps off an elevator.
Resident #49 was still waiting on X-ray results when inspectors completed their review.
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.
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: August 15, 2026 · Our methodology
HILLSIDE HEALTH CARE CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on April 24, 2026.
Staff described him as pleasant after the move.
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.