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Complaint Investigation

Lansdowne Village

November 17, 2025 · Saint Louis, MO · 4624 Lansdowne Avenue
Citations 3
CMS Rating 2/5
Beds 145
Provider ID 265351
Healthcare Facility
Lansdowne Village
Saint Louis, MO  ·  View full profile →
Inspection Summary

LANSDOWNE VILLAGE in SAINT LOUIS, MO — inspection on November 17, 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

FF0677
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During an observation and interview on 9/26/25 at 5:30 A.M., the resident lay in bed on his/her back.

The resident said he/she pressed the call light, and no one answered. He/She said he/she was soiled. An odor of urine was present in the resident's room.

The resident said he/she had been waiting for an hour.

The call light was not on upon arrival to the resident's room.

The resident was asked to press his/her call light again at 5:31 A.M.

The resident pushed the call light and said he/she was upset because this always happened at night. At 5:39 A.M., CNA I responded to the resident's call light.

Observation and interview on 9/26/25 at 5:40 A.M., showed CNA I entered the resident's room with some washcloths and an incontinence brief.

When CNA I removed the brief, it was soaked with urine. CNA I wiped the resident's groin areas and buttocks with wet washcloths and applied a clean brief.

The resident said it felt better after being soaked wet for a while.

During an interview on 9/26/25 at approximately 5:55 A.M., CNA I said he/she was responsible for about 20 residents during the night shift. He/She would answer call lights within five minutes.

Twenty residents were manageable.

The resident relied on staff for all toileting needs. 4.

During an interview on 9/30/25 at 7:48 A.M., Licensed Practical Nurse (LPN) O said regarding incontinence care, staff were provided in-service training a couple weeks ago.

Staff had a skills day.

Direct care staff were required to demonstrate providing care and they were quizzed. 5.

During an interview on 9/30/25 at 12:24 P.M., the Director of Nursing (DON) said residents who are incontinent of bowel and bladder should be checked every two hours. If residents are left wet for too long, there is an increased risk of skin breakdown. If a resident was left wet long enough for the cotton on the brief to stick to the skin and to saturate the brief and bedding, that is too long. 2595043

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Lansdowne Village

4624 Lansdowne Avenue Saint Louis, MO 63116

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 9/30/25 at 11:30 A.M., with the DM and Administrator, the DM said for residents on a puree diet, the oatmeal should be pureed.

Recipes should be followed. 5.

Review of Resident #24's meal ticket, dated 10/1/25, showed regular diet:-Breakfast notes: Two fresh fruit;-Lunch note: Two fresh fruit;-Dinner note: Two fresh fruit and a small salad with one slice of tomato and one slice of onion.

Observation and interview on 10/1/25 at 9:34 A.M., showed the resident in his/her room with his/her breakfast tray.

The resident was served bacon and two eggs. He/She said the breakfast is the same every day. He/She is supposed to get fresh fruit, and he/she does not. It even shows it on the meal ticket.

Most days he/she gets no fresh fruit.

During an interview on 10/1/25 at 12:19 P.M., with the Administrator, Director of Nursing (DON) and Corporate Administrator, they said meal tickets preferences should be followed when able.

There is always fresh fruit on hand.

The resident wants a lot of fresh fruit. He/She will go down to the kitchen and get it when he/she wants it. 1598315

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Lansdowne Village

4624 Lansdowne Avenue Saint Louis, MO 63116

SUMMARY STATEMENT OF DEFICIENCIES

Observation at 7:19 A.M., showed a roach crawled out of the bin that [NAME] J had just looked in and it crawled into the neighboring bin, that also contained serving spoons.

The cook began cooking pancakes. At 7:28 A.M., a baby roach crawled down the wall near the 3-vat sink.

At 7:38 A.M., a roach crawled along the back wall behind the oven, on the floor. It hid behind an electric cord. At 7:48 A.M., [NAME] J grabbed a spatula form the bin that the roach had most recently been seen crawling into and used it to flip pancakes. At 7:55 A.M., a very large, winged roach crawled out from under the stove and crawled to under the steam table.

Observation under the stove showed trash, napkins, plastic wrap, along with food debris and a buildup of dirt.

Observation of the kitchen on 9/29/25 at 7:16 A.M., showed debris on the kitchen floor. A dead roach in the wash bin of the 3-vat sink. A roach smashed on the ground in front of the steam table. At 7:23 A.M., [NAME] K said he/she had seen some roaches but not too bad.

The facility is working on it.

The pest control company comes, and staff clean daily.

During an observation and interview on 9/29/25 at 9:19 A.M., the Dietary Manager (DM) said regarding pests, she had not seen any roaches.

Food debris should not be left overnight.

Staff should clean before they leave.

Closing duties include clean up all the food debris before leaving for the day.

The surveyor showed the DM a dead roach that lay on the bottom shelf of the steamtable.

The DM said it should have been cleaned up.

During an interview with the Administrator, Director of Nursing, and Corporate Administrator on 10/1/25 at 12:19 P.M., the Administrator said when the pest control company comes, they do not leave any recommendations of things to do to decrease the chance of getting pests with her. If they left recommendations, it would be with the maintenance supervisor.

Part of an effective pest control program includes cleaning the kitchen of food debris and trash. 257375925821422584514

Facility ID:

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 LANSDOWNE VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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