Nazareth Living Center
NAZARETH LIVING CENTER in SAINT LOUIS, MO — inspection on November 17, 2025.
Found 1 citation. 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.
Inspection Findings
During interviews on 10/22/25 at 12:00 P.M. and on 10/23/25 at 10:30 A.M., CNA A said he/she did not receive report on the morning of 10/13/25 when he/she started his/her shift and did not know the resident was injured.
When he/she went to check on the resident around 9:00 A.M., to get the resident ready for breakfast, he/she noticed the large knot on the resident's head. He/She did not say anything because he/she thought someone would have already reported it since the knot did not look new and the blood was dried on the cut.
During an interview on 10/23/25 at 2:00 P.M., the hospice social worker said he/she got to the facility around 10:00 A.M. on 10/13/25.
The resident was sleeping so he/she sat by his/her bedside for a little while until he/she woke. He/She noticed a large spot of blood on the resident's pillow and dried blood on the bed rail.
When the resident turned over, to his/her left side, the social worker noticed a golf sized knot on his/her head with dried blood on it. He/she immediately went to the nurse's station to report the injury to the nurse who had no idea what happened.
The nurse checked the resident's medical record to see if there was any note about what happened and there was nothing documented.
During an interview on 10/22/25 at 1:50 P.M., Licensed Practical Nurse (LPN) D said he/she was not working the resident's floor on 10/13/25, but he/she was standing at the nurse's station when the hospice staff came and reported the injury. He/She and the floor nurse went in and assessed the resident together.
The resident had a large knot on his/her head.
During an interview on 10/22/25 at 2:00 P.M., LPN D said on 10/13/25, the hospice social worked came to the desk and questioned him/her about the resident's injury. No one said anything to him/her in shift change about the resident being injured.
When he/she went and assessed the resident, he/she had a significant knot on his/her head from the front to the back.
Review of the resident's medical record, dated 10/23/25, showed:-On 10/9/25 at 2:44 P.M., vitals documented;-On 10/13/25 at 8:41 P.M., vitals documented;-No vitals documented between 10/9/25 at 2:44 P.M. and 10/13/25 at 8:41 P.M.;-No documented assessment or neurological checks on 10/13/25 from 9:00 A.M. to 11:30 A.M.
During an interview on 10/22/25 at 2:45 P.M., the Director of Nursing said the staff should have reported the incident of the tray to the nurse if it hit the resident even if there were no immediate injuries.
The staff should have also immediately reported the injury to the nurse as soon as it was noticed.
Not reporting the incident and/or injury could delay assessment and care for the resident.
All this information should have been documented.
During an interview on 10/22/25 at 3:15 P.M., the Administrator said he expected staff to report all resident injuries immediately so care can be provided.
This information should also be documented. 2646327
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