Pine Grove Manor
PINE GROVE MANOR in SAINT LOUIS, MO — inspection on December 22, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 12/19/25 at 8:13 A.M., the Interim Administrator said the
resident's assigned CNA, CNA D said nothing unusual happened overnight.
The resident was his/her
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.
265828 12/22/2025
Pine Grove Manor 4359 Taft Avenue Saint Louis, MO 63116
During an interview on [DATE] 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).
265828 12/22/2025
Pine Grove Manor 4359 Taft Avenue Saint Louis, MO 63116
Observation on 12/18/25 at 11:25 A.M., showed
were without bandages, dressings, or tubi-socks.
During an interview, the resident said he/she has
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.
265828 12/22/2025
Pine Grove Manor 4359 Taft Avenue Saint Louis, MO 63116
During an interview on 12/19/25 at 8:12 A.M., LPN B said he/she did not prime the insulin pen before
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.