Pine Grove Manor: CPR Mask Missing During Code - MO
The resident died.
Federal inspectors who arrived at the facility at 4359 Taft Avenue following a complaint rated what they found as Immediate Jeopardy, the most serious level of harm designation available under the federal inspection system, one that signals a situation inspectors believe has caused or is likely to cause serious injury or death.
The inspection, completed December 22, 2025, documented what happened during the code in detail that is difficult to read and impossible to dismiss. Staff eventually managed to give rescue breaths once a mask was located. They eventually got oxygen flowing from the tank on the crash cart. But the delays happened during the minutes that matter most in a cardiac emergency, when every second without compressions or oxygen to the brain narrows the window for survival.
The resident did not survive resuscitation.
The facility's administrator, interviewed by inspectors, said he was not sure why there was no mask. He acknowledged that the checklist showed staff had checked off the mask as present during an inspection of the crash cart on the night shift before the code. Night shift staff are responsible for checking the crash cart. He said it was "a concern" that staff marked the mask as available when it was not.
That word, concern, is doing a great deal of work in a sentence about a dead resident and a falsified equipment log.
The crash cart is the single piece of emergency equipment a nursing home keeps ready for exactly this moment. It exists for no other purpose. The mask on that cart exists so that when a resident stops breathing in the middle of the night, the person responding doesn't have to search, doesn't have to improvise, doesn't have to stand at the bedside of a person in cardiac arrest wondering where the equipment is. The checklist that accompanies the cart exists so that someone in authority can verify, shift by shift, that everything is in place. On the night before this resident's code, someone ran through that checklist and marked the mask as present. It was not present.
The administrator told inspectors the pen and key needed to turn on the oxygen tank were available on the side of the cart, and that he would expect staff to know how to use them. Staff were eventually able to get oxygen flowing during the code. But the inspection record makes clear that "eventually" is the operative word, and that the delays were real.
The facility's Medical Director said he was informed about the code after the fact. He told inspectors he expects staff to follow American Heart Association standards when performing CPR. He noted that when EMS arrives, compressions should continue until emergency personnel are ready to take over. If compressions are stopped too soon, he said, there is a risk of delay and potentially death. He also addressed the question of suction, noting that if a resident has excess secretions, clearing the airway could be beneficial, though what takes priority depends on the situation. On the question of rescue breaths, he said the research supports giving them when they can be completed while maintaining compressions.
The inspection record does not detail precisely how long the mask was unavailable, or exactly how the sequence of events unfolded from the moment staff noticed the resident was not breathing to the moment EMS arrived. What it documents is that the mask was missing, that the checklist said otherwise, that staff struggled to give breaths, and that the resident died.
The administrator confirmed he was aware of the resident's code status when he noticed the resident was not breathing. The inspection report does not specify the resident's name, age, or underlying conditions. What it records is the outcome.
Inspectors determined at the time of their abbreviated survey visit that the violation rose to the Immediate Jeopardy level, the federal designation reserved for situations where a facility's failure has caused or is likely to cause serious harm or death to a resident. Before inspectors left the facility, Pine Grove Manor had implemented corrective action sufficient for inspectors to lower the deficiency from Immediate Jeopardy to a D-level violation, the lowest severity tier. The inspection report notes that a final revisit will be conducted to determine whether the facility is in substantial compliance with participation requirements.
The lowering of the severity level at exit is a procedural step. It reflects that the facility took some action before inspectors walked out the door. It does not mean the resident is alive. It does not mean the checklist was accurate when it mattered. It does not resolve the question of who checked off that mask as present, or why.
The inspection report also notes explicitly that the lowered severity designation does not indicate the facility has complied with Missouri state law requiring prompt remedial action for Class I violations, the state's own most serious category of nursing home deficiency.
A crash cart checklist is one of the most basic safeguards in a nursing home. It takes minutes to complete. Its entire purpose is to ensure that when the worst moment arrives, the equipment is where it is supposed to be. At Pine Grove Manor, someone completed that checklist on the night shift before this resident's code. They marked the mask as present. They were wrong, or they did not check, or they checked without looking. The inspection report does not say which. What it says is that when staff stood at that cart during an active code and reached for the mask, it was not there.
The administrator called that a concern.
The resident's family, if they have one, is left with something harder to name.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PINE GROVE MANOR in SAINT LOUIS, MO was cited for violations during a health inspection on December 22, 2025.
The inspection, completed December 22, 2025, documented what happened during the code in detail that is difficult to read and impossible to dismiss.
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.