Pine Grove Manor

In the surveyor’s words

From the most serious findings on record at Pine Grove Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 3, 2024

  Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining safe water temperatures in resident rooms on the North and South halls between 105 degrees Fahrenheit (F) and 120 F for 16 (Residents #49, #14, #12, #15, #54, #34, #8, #3, #27, #5, #43, #258, #18, #11, #52, and #40) of 31 sampled residents. The hot water temperatures in these resident room bathrooms ranged from 141 to 153 degrees F. The census was 55. The administrator was notified on 3/28/24 at 7:00 P.M., of an immediate jeopardy (IJ), which began on 3/28/24. The IJ was removed on 3/29/24 as confirmed by surveyor verification. […]

• Immediate jeopardy, isolatedF678Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to provide cardiopulmonary resuscitation (CPR, life saving measures) effectively to include rescue breaths, to a resident when the supplies needed to run a code were not available on the crash cart. This resulted in a delay of up to 9 minutes from the time CPR was initiated until rescue breaths and oxygen could be administered, for one resident (Resident #1). Staff were not knowledgeable on how to work the suction machine, resulting in an occluded airway. In addition, staff failed to ensure Emergency Medical Services (EMS) was in the room and ready to take over compressions before stopping CPR. Eighteen residents were identified to be a full code. The census was 48. […]

• Actual harm, isolatedF689Jul 1, 2026

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), who was non-weight bearing on his/her left leg and required the use of a Hoyer (mechanical lift) for transfers, received adequate assistance to prevent accidents when Certified Nurse Aide (CNA) A and Certified Medication Technician (CMT) B performed an assisted transfer without the use of a mechanical lift or gait belt. The resident reported pain during the transfer and sustained a fractured fibula (calf bone). The sample was 7. The census was 52 The Administrator was notified on 07/01/26 of the past non-compliance, which occurred on 05/05/26. Nursing staff were in-serviced on resident transfers. The deficiency was corrected on 05/14/26. […]

• Actual harm, isolatedF600Oct 13, 2023

  Based observation, interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #3). On 9/25/23 at 4:48 A.M., Certified Nurse Aide (CNA) A went into the resident's room and cursed at the resident to lay in his/her bed, calling the resident derogatory names and verbally threatening physical harm to the resident. The census was 65. The administrator was notified on 10/26/23, of the past non-compliance. The facility provided training and in-services for all staff regarding the facility's abuse prevention and resident rights policies. Review of the facility's Abuse Policy, revised 9/1/18, showed: -Purpose: The facility maintains a no tolerance policy on any form of abuse towards our residents. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2022

  Based on observation and interview, the facility failed to maintain food under sanitary conditions when staff failed to label and date opened/stored food, to ensure dishes were air dried, kitchen equipment remained clean and floors were free of dust, grease and grime. In addition, staff failed to routinely test the chemical dishwasher prior to use. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 59. Review of the Food Storage Policy, procedure guidelines, undated, showed: Food stored in freezers and refrigerators are covered, labeled and dated, especially foods taken from their original containers and leftovers. […]