Pine Grove Manor

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's room when CNA F reported he/she found the resident's sleeves tied. He/She did go in once

before that to give the resident his/her ordered medication and he/she was sitting up, covered up to his/her shoulder and the CNA was feeding him/her breakfast. His/Her arms were under the blanket. He/She assessed the resident. He/She does have bruising to the right side of his/her face and arm, but that was from a prior fall. No new injuries noted. The resident does have some behaviors. He/She yells out and is resistive to care at times. He/She will hit at times. During an interview on 12/19/25 at 6:26 A.M., CNA I said he/she worked on the other hall on the night shift on the night of December 17th through the morning of the 18th. He/She did not work on the resident's hall at all that night and did not know anything about the sleeves being tied. During an interview on 12/19/25 at 8:13 A.M., the Interim Administrator said the Director of Nursing (DON) called the night shift yesterday and interviewed them about the resident's sleeves being tied. During an interview on 12/19/25 at 8:18 A.M., the DON said when he talked to the resident's assigned CNA, CNA D said nothing unusual happened overnight. The resident was his/her normal talkative self when put to bed. He/She got the resident dressed in the morning. When he mentioned the resident's sleeves being tied together, CNA D said he/she did not know anything about it. During an interview on 12/19/25 at 8:26 A.M., LPN C said he/she was the resident's nurse on the night shift the night of December 17th through the morning of the 18th. He/She did not have to go into the resident's room. The resident does not need any nursing care on the night shift. The resident's door is always open, and he/she could be seen from the open door and seemed peaceful. No issue was reported to him/her regarding the resident. During

an interview on 12/19/25 at 10:10 A.M., the Interim Administrator and DON said it was never determined who tied the resident's sleeves together. They would expect residents to be free from restraints.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Grove Manor

4359 Taft Avenue Saint Louis, MO 63116

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

set up, he/she tested it with some saline, and it was not working. Nothing came through when he/she tested it. He/She even put his/her hand over the end to get the suction to work, but he/she was never able to get it to work. Then 911 came and that is the last he/she did with it. He/She was never able to use the suction on

the resident, and he/she did not recall anyone else using the suction. It took about five minutes to get to set up, and it did not work. During an interview on [DATE REDACTED] at 10:01 A.M., with the DON and Interim Administrator, the DON said he was the one running the code. His responsibility in running the code is to assign duties and make sure proper compression are given, proper rate, etc. Breaths should be given at a rate of two every 30 compressions. During the code, staff were eventually able to give breaths, but initially

they did not have the mask available to give breaths. He was not sure why there was no mask. Regarding

the checklist, the check list does show that staff checked off the mask was present on the crash cart during

the check on the [DATE REDACTED]. Night shift are the ones who check the crash cart. It is a concern that staff marked

the mask as available when it was not. He noticed the resident was not breathing and he was aware of his/her code status. The pen/key needed to turn on the oxygen was available on the cart and he would expect staff to know how to use it to turn on the oxygen tank. It was located on the side of the crash cart.

Staff were able to eventually get the oxygen flowing during the code. When EMS arrives, compressions should continue until they are ready to take over. If stopped too soon, there is a risk of delay in compressions and potentially death. During an interview on [DATE REDACTED] at 1:40 P.M, the Medical Director said

he was informed after the fact the resident was coded, and staff was unsuccessful in resuscitation. He expects the facility staff to follow policy and AHA standards of practice when giving CPR. Depending on the situation, if the resident has excess secretions, suction could be beneficial to clear the airway, but it depends on what is most urgent at the time. In general, research says rescue breaths are beneficial if they can be completed while also maintaining routine compressions. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation,

interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Grove Manor

4359 Taft Avenue Saint Louis, MO 63116

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

dated 12/12/25, showed right lower leg (front) with closed scabs, bruising, and redness. Left lower leg (front) with closed scabs, bruising and redness. Review of the resident's ePOS and MAR for December 2025, showed the Wound Doctor's orders from 12/11/25 for treatment to the resident's right medial shin and left anterior shin, were not added to the ePOS or MAR. Review of the resident's care plan, in use at the time of survey, showed no documentation related to the resident's wounds. Observation on 12/18/25 at 11:25 A.M., showed the resident had an irregularly shaped wound to the right inner mid-calf with defined and pink edges. The wound was scabbed over. The left upper leg had scrape-like marks that were scabbed.

Both legs were without bandages, dressings, or tubi-socks. During an interview, the resident said he/she has wounds on his/her right toes, right shin, left shin, and buttocks. A doctor prescribed medication nine days go, but he/she has not received the medication. The resident believes his/her wounds are one to two months old. During an interview on 12/18/25 at 11:06 A.M., Licensed Practical Nurse (LPN) A said there are two nurses working on day shift. The desk nurse does all the clerical work and glucose checks with insulin administration. The floor nurse passes all the medications and does wound treatments. Every Thursday, the facility's Wound Doctor makes rounds on each resident with the Director of Nursing (DON). If

the wounds are new, the nurses can measure and record them; however, the Wound Doctor measures the wounds and documents the findings in his notes. During an interview on 12/18/25 at 12:59 P.M., the DON said the Wound Doctor saw the resident last week, on 12/11/25. At that time, the he/she was out of the facility. When he/she returned on Monday, 12/15/25, a skin assessment was completed; however, no physician orders were transcribed to the ePOS. The desk nurse is responsible for entry of all orders from providers. The DON was unaware of any orders written from the provider because the desk nurse did not transcribe them into the electronical medical record (EMR). During an interview on 12/19/25 at 1:17 P.M., LPN A said, the only order he/she put in was to be seen by the Wound Doctor. The Wound Doctor, did not given any order(s) to place. During an interview on 12/18/25 at 1:44 P.M., the Wound Doctor said he expects staff to follow all physician orders. His recommendation was for staff to administer the treatments as he ordered on 12/11/25. 2688758

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Grove Manor

4359 Taft Avenue Saint Louis, MO 63116

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly;-If the pen is not primed before each injection, you may get too much or too little insulin;-To prime the pen, turn the dose knob to two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding the pen with needle pointing up.

Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. Observation on 12/19/25 at 8:12 A.M., showed LPN B did not prime the insulin pen before administering the insulin to the resident. During an interview on 12/19/25 at 8:12 A.M., LPN B said he/she did not prime the insulin pen before using it on the resident. The purpose of priming first is to ensure the pen is functional prior to administering insulin. During an interview

on 12/19/25 at 12:03 P.M., the Director of Nursing (DON) said he expects staff to prime insulin two units, per the facility's policy. The needle hub is filled up with air and by not priming it, the residents received air instead of the recommend dose of insulin ordered. 2694223

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Facility ID:

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