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Complaint Investigation

Hillside Health Care Center

March 20, 2025 · Saint Louis, MO · 1265 Mclaran Avenue
Citations 3
Beds 208
Provider ID 265585
Healthcare Facility
Hillside Health Care Center
Saint Louis, MO  ·  View full profile →
Inspection Summary

HILLSIDE HEALTH CARE CENTER in SAINT LOUIS, MO — inspection on March 20, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF684
Mechanical offloading and pressure reducing devices; Few affected

Review of the Wound Management Policy, revised 10/24/22, showed:

-Purpose: provide a system for the treatment and management of residents with wounds including pressure and non-pressure ulcers;

-Definitions: Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy.

The diabetic ulcer characteristically occurs on the foot;

-Procedure: Assessment:

-A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident;

-Upon identification of a wound the licensed nurse will:

-Measure the wound (length, width and depth);

-Initiate a wound monitoring record sheet:

-A wound monitoring record will be completed for each wound;

-If the wound monitoring record is not used, documentation will be recorded within the medical record which may include nursing notes, treatment records or care plans;

-An assessment of care needs for pressure ulcer and wound management will be made with emphasis on, but not limited to:

-Identifying risk factors;

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

265585

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 265585 B.

Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

F-F686 cited under Event ID 4F7E12

Based on observation, interview and record review, the facility failed to follow the facility's policy regarding wound care when staff failed to ensure continued wound care treatments following a hospitalization with an identified pressure injury (a localized area of skin damage that develops when prolonged pressure is applied to the body) to the tailbone (sacrum) upon discharge for one resident (Resident #14).

The failure resulted in the worsening of the identified sacral wound and the development of two additional pressure injuries.

Staff failed to ensure accurate documentation, notify the physician of worsening wounds since hospitalization and obtain wound care orders. In addition, staff failed to ensure timely wound dressing change to identified saturated dressings (Resident #16).

The census was 145.

265585

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 265585 B.

Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Rehab and Healthcare Center 1265 McLaran Avenue Saint Louis, MO 63147

F-F697 cited under Event ID 4F7E12

Based on observation, interview and record review, the facility failed to implement an effective pain management regime for two sampled residents (Resident #18 and #14).

Staff failed to notify ensure Resident #18, who experienced pain related to metastatic breast cancer with osseous (bone) involvement, most severe over bilateral lower extremities, received pain medications as ordered by the physician and failed to notify the primary physician when pain medications were not delivered from the pharmacy and of medications available in the emergency kit.

The resident experienced uncontrolled pain and was transferred to the hospital two days after admission to the facility.

For Resident #14, the facility staff failed to provide effective pain relief when, during care, staff removed wound dressings which were adhered to the wound sites.

The resident had so much pain, he/she was observed to cry and requested Certified Nurse Aide (CNA) D spray over the counter Bactine (relieves the pain and itch of minor cuts, scrapes and burns on contact) onto the buttock wound sites.

The sample was 16.

The census was 145.

265585

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT LOUIS, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HILLSIDE HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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