How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SAINT LOUIS, MO, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from PINE GROVE MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 265828.

Has this facility had violations before?

To check PINE GROVE MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.

Inspection Report

Pine Grove Manor: Resident Found With Sleeves Tied - MO

June 12, 2026

Saint Louis, MO

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Healthcare Facility

Pine Grove Manor

Saint Louis, MO · 1/5 stars

The incident occurred sometime during the overnight shift of December 17-18. CNA F discovered the resident's sleeves tied when entering the room that morning. Earlier, the same aide had given the resident medication and watched another staff member feed breakfast. The resident's arms were under a blanket then, with no visible restraints.

The resident has a history of behavioral issues, including yelling and hitting staff members during care. Inspectors noted bruising on the right side of the person's face and arm from a previous fall, but found no new injuries.

Multiple staff members denied knowledge of the restraint. CNA D, assigned to the resident that night, told the Director of Nursing nothing unusual happened overnight. The resident was "his/her normal talkative self" when put to bed and got dressed normally in the morning. When asked about the tied sleeves, CNA D claimed no knowledge of the incident.

LPN C, the resident's night shift nurse, never entered the room during the shift. The resident required no nursing care overnight. The nurse could see into the room through an open door and reported the resident "seemed peaceful."

CNA I worked the night shift but on a different hall and knew nothing about the tied sleeves.

The Director of Nursing interviewed night shift staff after learning of the incident. No one provided information about who tied the resident's sleeves or why.

The Interim Administrator and Director of Nursing acknowledged they never determined who restrained the resident. Both said they expect residents to remain free from restraints.

Federal inspectors cited the facility for failing to protect residents from unauthorized restraints.

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

Editorial Standards

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 15, 2026 · Our methodology

Quick Answer

PINE GROVE MANOR in SAINT LOUIS, MO was cited for violations during a health inspection on December 22, 2025.

The incident occurred sometime during the overnight shift of December 17-18.

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.

Frequently Asked Questions

What happened at PINE GROVE MANOR?: The incident occurred sometime during the overnight shift of December 17-18.
How serious are these violations?: Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
What should families do?: Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SAINT LOUIS, MO, (5) Report any new concerns directly to state authorities.
Where can I see the full inspection report?: The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from PINE GROVE MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 265828.
Has this facility had violations before?: To check PINE GROVE MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.