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Complaint Investigation

Hillside Health Care Center

March 26, 2026 · 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 26, 2026.

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

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies

Review of the resident's medical record, showed no documentation regarding an altercation on with another resident on 3/21/26.

During an interview on 3/25/26 at 10:43 A.M., the resident said Resident #1 hit him/her in his/her chest.

Review of the DHSS system for reporting alleged violations, showed no documentation of the facility submitting a report regarding a physical altercation between Residents #1 and #2.

During an interview on 3/25/26 at 2:00 P.M., Licensed Practical Nurse (LPN) A said another resident came and told him/her there was a fight happening in a room across from him/her. LPN A went to the room shared by Residents #1 and #2.

When he/she arrived, LPN A saw Resident #2 was standing over Resident #1, yelling. LPN A asked what happened and each resident said they hit each other.

During an interview on 3/26/26 at 12:40 P.M., the Director of Nursing (DON) said she expected the facility's Abuse and Neglect Policy to be followed as written.

This would include reporting to the state survey agency in the required timeframe.

The DON did not know why this did not happen.

During an interview on 3/25/26 at 12:30 P.M., the Administrator said when she initially heard about the incident, she was told there was no physical contact so she did not feel the need to report the incident to DHSS.

265585 03/26/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Review of the resident's care plan, in use at the time of survey, showed no documentation regarding an altercation with another resident on 3/21/26.

Review of the resident's medical record, showed no documentation regarding an altercation on with another resident on 3/21/26.

During an interview on 3/25/26 at 10:43 A.M., the resident said Resident #1 hit him/her in his/her chest.

Review of Resident #8's comprehensive MDS, dated [DATE], showed: -Cognitively intact;-Diagnoses included anxiety and schizophrenia.

During an interview on 3/26/26 at 11:24 A.M., Resident #8 said he/she woke up and heard two residents arguing in the hall. He/She went to get Licensed Practical Nurse (LPN) A. He/She did not see anyone get hit.

Before today, no one asked him/her about the incident.

During an interview on 3/25/26 at 2:00 P.M., LPN A said Resident #8 came and told him/her there was a fight happening in a room across from him/her. LPN A went to the room shared by Residents #1 and #2.

When he/she arrived, LPN A saw Resident #2 was standing over Resident #1, yelling. LPN A asked what happened and each resident said they hit each other. LPN A did not see either resident hit each other. He/She separated the residents and contacted the on-call supervisor, the Assistant Director of Nursing (ADON). LPN A was not asked to write a statement about the altercation. He/She thought he/she documented the incident in the medical records for both residents.

During an interview on 3/26/26 at 8:35 A.M., the ADON said he/she was the on-call supervisor when LPN A notified him/her of the altercation between Residents #1 and #2. LPN A never said the residents hit each other. LPN A only said the residents were in an argument.

Had the ADON known there was a physical altercation, he/she would have reported it to the Administrator immediately.

During an interview on 3/26/26 at 12:40 P.M., the Director of Nursing (DON) said she expected the facility's Abuse and Neglect Policy to be followed as written.

This would include giving accurate information regarding the incident.

This will allow a thorough investigation to happen, which would include gathering statements from residents and staff.

The DON did not know why this did not happen.

During an interview on 3/25/26 at 12:30 P.M., the Administrator said she did not interview Resident #1 because the resident was not in the facility.

She obtained interviews from other people but did not document them.

She should have gotten statements from all involved parties, and should have conducted a thorough investigation, per the facility's policy. 29602492964554

265585 03/26/2026

Hillside Health Care Center 1265 McLaran Avenue Saint Louis, MO 63147

Review of the facility's staffing sheets for March 2026, showed the following:-On 3/1/26, no RN scheduled;-On 3/7/26, no RN scheduled;-On 3/9/26, no RN scheduled;-On 3/14/26 through 3/17/26, no RN scheduled;-On 3/21/26 and 3/22/26, no RN scheduled;-On 3/25/25, no RN scheduled.

During an interview on 3/26/26 at 12:40 P.M., the Director of Nursing (DON) said she was the on-call person for the days in which no RN was scheduled and she thought that would count as the facility's RN coverage.

The DON said she was in the building at times on those days, but not eight hours.

During an interview on 3/26/26 at 12:40 P.M., the Administrator said she was aware there needed to be an RN scheduled for at least eight hours a day, seven days a week.

The DON is salaried so she does not clock in for when on duty. 2800874

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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