Pine Grove Manor: Medication Error Pattern - MO
The resident told inspectors on December 18 that wounds on their right toes, right shin, left shin, and buttocks were one to two months old. "A doctor prescribed medication nine days ago, but he/she has not received the medication," according to the inspection report.
Inspectors observed irregularly shaped wounds on the resident's right inner mid-calf with defined pink edges that were scabbed over. The left upper leg showed scrape-like marks, also scabbed. Neither leg had bandages, dressings, or protective coverings.
The facility's wound doctor had examined the resident on December 11 and written treatment orders for wounds on the right medial shin and left anterior shin. But those orders never made it into the electronic medical record system.
The Director of Nursing admitted the breakdown during interviews. She said the resident was out of the facility when the wound doctor visited December 11. When they returned December 15, staff completed a skin assessment but failed to transcribe the physician's orders.
"The desk nurse is responsible for entry of all orders from providers," the nursing director explained. "The DON was unaware of any orders written from the provider because the desk nurse did not transcribe them."
The desk nurse claimed they only entered an order for the resident to see the wound doctor, insisting the doctor "did not give any order(s) to place."
The wound doctor contradicted this account, telling inspectors he expects staff to follow all physician orders and recommended they administer treatments as he had ordered December 11.
The facility's care plan contained no documentation about the resident's wounds, despite their obvious presence and the doctor's written treatment orders.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pine Grove Manor from 2025-12-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PINE GROVE MANOR in SAINT LOUIS, MO was cited for violations during a health inspection on December 22, 2025.
The resident told inspectors on December 18 that wounds on their right toes, right shin, left shin, and buttocks were one to two months old.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.