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Garrison Care Center Ratings & Violations

Statistics show that nursing home residents develop bedsores (pressure sores; pressure wound; pressure ulcers; decubitus ulcers) twice as often as patients in hospitals. Fortunately, if the nursing staff takes appropriate measures, every bedsore is preventable. Sadly, the St. Louis elder abuse attorneys at Rosenfeld Injury Lawyers LLC have handled many cases where the resident suffered serious injury or wrongful death caused by a preventable bedsore due to the negligent actions of the nursing staff.

Bedsores develop when blood flow is restricted to bony areas on the body caused by constant pressure. Without reposition or turning, certain areas including the ankles, heels, knees, hips, sacrum (tailbone), shoulders and elbows can quickly develop a bedsore when the skin and underlying tissue is deprived of oxygen and nutrients. In many incidences, the resident lacks the capacity to turn or reposition their body without the assistance of the nursing staff.

Garrison Care Center

Garrison Care Center is a 90-certified bed for profit Medicare/Medicaid-participating facility providing nursing services to residents of St. Louis, St. Louis County and St. Clair County, Illinois. The facility is located at:

2939 Magazine Avenue
St. Louis, Missouri 63106
(314) 531-0500

St. Louis Nursing Home Resident Safety Concerns

To ensure families are fully informed about nursing facilities throughout the United States, both the federal government and state agencies routinely update their nursing home databases to reflect the most currently filed complaints, opened investigations, safety concerns, and health violations. The updated information can be found on numerous sites including

Currently, Garrison Care Center maintains an overall four out of five available star rating compared to all other facilities in the United States. This includes five out of five stars for quality measures and three out of five stars for both staffing issues and health concerns. However, our St. Louis nursing home neglect attorneys have found numerous concerns involving this facility that include:

  • Failure to Provide Residents Proper Treatment to Prevent the Development of a New Bedsore or Allow an Existing Bedsore to Heal

    In a summary statement of deficiencies dated 05/18/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility's failure to "monitor, assess, document and provide appropriate pressure ulcer care for [one resident at the facility] identified as having pressure ulcers and no problems were found.” The state investigator noted that “the resident [at the facility] had not been identified as having a pressure ulcer [but] was found to have an untreated pressure ulcer.”

    This incident involved resident at the facility with a Braden Scale assessment score of 14 where any score 12 or higher represents a high risk for the development of pressure ulcers. The state investigator reviewed the resident’s 10:30 AM 04/24/2015 Nurse’s Notes that indicated “two small open areas to the right buttocks [measuring] 0.5 centimeters by 5.0 centimeters [...and] 0.5 centimeters by 2.0 centimeters.” The notes revealed that the resident had “a wound bed pink, no odor, physician made aware.”

    After the Assistant Director of Nurses evaluated the resident’s sores, the resident’s wounds were categorized as “Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough [dead skin]. May also present as an intact or open/ruptured blister.” Between 04/24/2015 and 04/30/2015, there was “no further documentation regarding the pressure ulcer.” The investigator noted that an evaluation of the resident’s wounds was documented at 9:00 AM on 04/30/2015 revealing that the “pressure ulcer to the right buttocks heal, treatment discontinued, no new areas reported; no further documentation regarding the right buttocks pressure ulcer until 05/12/2015.”

    However, five days later on 05/17/2015 at 8:30 AM, new documentation revealed that the resident’s pressure ulcer was now described as “reopened area to the right buttocks, wound bed was slough (dead tissue) surrounding tissue moist with moderate amount of serosanguinous (blood-tinged drainage) fluid, measured: 7.4 centimeters by 6.0 centimeters, depth less than 0.2 centimeters, treatment order obtained.” The wound had increased significantly in size since it was first discovered 23 days earlier.

    The state investigator noted that the action of the nursing staff at Garrison Care Center failed to follow the facility’s policy titled Wound Protocol that reads in part:

    “Whenever a pressure ulcer is identified on a resident, the following procedure to be initiated: Nurse is to begin the process immediately; document an assessment of the wound [including its] location, stage, size (length, width and depth), undermine/tunneling (area under wound edge), wound bed, drainage, peri-tissue (area surrounding the wound); notify the physician; document treatment orders if needed on Physician Order Sheet (POS)/TAR (Treatment Administration Record); notify Director of Nursing/Assistant Director of Nursing; MDS Nurse; educate staff on positioning problems if needed.”

St. Louis Nursing Home Abuse Lawyers

If you suspect your loved one has suffered from a preventable bedsore caused by the negligent actions of the nursing staff at Garrison Care Center or any nursing facility, Rosenfeld Injury Lawyers LLC can take quick action to ensure the nursing staff and facility is held legally and financially responsible for your loved one's harm.

To ensure that your financial compensation claim is successfully resolved, we urge you to contact our St. Louis nursing home abuse law firm at (888) 424-5757 today to schedule an appointment for a free, comprehensive case evaluation. No upfront payments are required because we accept all personal injury cases and wrongful death lawsuits through contingency fee agreements.

Disclaimer: The above inspection findings are take from public sources including the State Department of Health and from Medicare inspection conducted at the facility at least every fifteen months. Rosenfeld Injury Lawyers LLC cannot confirm that the content on this site is the most recent information related to the facilities mentions.

The inspection findings published are not complete. You may find the most up to date information here: or

The deficiencies/citations listed on this page may have been corrected or substantially corrected after the date of the inspection and date of publishing this material. This page is a legal advertisement and a resource of information for visitors. This material is not endorsed by the facility noted or by any governmental agency. Rosenfeld Injury Lawyers LLC does not have any affiliation with the facility.

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