Hillside Health Care Center: Self-Harm Left Unaddressed - MO
The resident arrived at Hillside's facility on McLaran Avenue missing an index finger on the right hand. The stump was wrapped in dressings. Within weeks, staff were watching the resident raise both arms, pull the dressings off the wounded hand, and chew on them. The resident had also been biting the remaining fingers. At some point before inspectors arrived, the behavior had gotten bad enough that the facility sent the resident out. When the resident came back, the hand was wrapped again.
Nothing else changed.
CNA JJ told inspectors that the resident would get angry if there was no cheese on the eggs at breakfast, and would respond by striking themselves in the head with their arms and cursing at staff. CNA JJ's solution was to wheel the resident out to the hallway near the nurses' station, where someone might notice. If CNA JJ personally saw the resident bite the hand or hit themselves, CNA JJ would try to stop it. There were no scheduled checks. There was no one-on-one monitoring. There was no written intervention for the self-mutilation.
CNA KK and CNA MM told inspectors they were not aware of any special interventions for the resident. CNA OO said the resident was always upset, wanted to smoke constantly, and would bang on the wall from the bed, which had been pushed against it. CNA OO had been telling nurses about the behaviors. CNA OO did not know of any plan that addressed the finger-biting.
LPN I admitted knowing the resident had bitten fingers before. LPN I also acknowledged the documentation of the resident's behaviors was poor. When the resident had outbursts, LPN I did not contact the psychiatrist. The reason: the resident was always difficult, and the behaviors were nothing new. LPN I told inspectors the resident needed stronger medication to stabilize their moods. No one had made that call.
Wound Nurse NN confirmed the resident was frequently left alone in the room and that the resident was always chewing the dressings off the right hand. Wound Nurse NN was not aware of any special intervention for staff to monitor the resident either.
The Social Service Director had been at the facility for about one month and told inspectors she did not know the resident well. The Social Service Designee said that when the resident was first admitted, not much was known about them. After a few weeks, the nibbling on fingers got bad enough to send the resident out for outside care. When the resident returned with a wrapped hand, the facility apparently treated that as the end of the problem rather than the beginning of one.
Inspectors classified the violation as immediate jeopardy, the most serious level of harm in federal nursing home oversight, meaning the situation posed a risk of serious injury or death to the resident.
What makes the finding particularly stark is not that the staff were indifferent. CNA JJ moved the resident to the hallway to keep watch. CNA OO kept telling the nurses. LPN I knew the resident needed better psychiatric medication. The Wound Nurse visited regularly enough to observe the dressings being chewed off every time. The knowledge was everywhere. It just never became a plan, a documented check schedule, a phone call to a psychiatrist, or a line in a care record that anyone was required to follow.
The resident had already lost a finger. The hand that remained was wrapped in dressings the resident pulled off and put in their mouth. Staff were intervening when they happened to be present and doing nothing when they were not, which, by multiple accounts, was most of the time.
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 16, 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 arrived at Hillside's facility on McLaran Avenue missing an index finger on the right hand.
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.