Pine Grove Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 10, 2025

  Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. The facility failed to ensure Resident #1 was in safe position prior to incontinent care. Resident #1 rolled off her bed during incontinent care on 12/06/25.Resident #1 sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction (lower leg bone broken into multiple pieces tilted at an angle and slight displacement of the bone fragments) and a non-displaced fracture of the right distal femoral shaft(middle section of the femur-the bone breaks in one spot and remains aligned).This failure could place residents at risk of severe… […]

• No harm, potential for more than minimal, widespreadF812Jul 24, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. The facility failed to store food in accordance with professional standards in that: 1. Dry storage items were improperly stored. 2. Frozen foods were unlabeled and open to air. These failures could place residents at risk for food contamination and foodborne illness. Findings: During an observation of the facility kitchen on 7/22/24 at 9:10 am revealed the following: *Flour was stored with a scoop inside the container. […]

• No harm, potential for more than minimal, widespreadF812Jun 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation. The dish machine tested at 10 ppm of chlorine and the temperature gauge was stuck at 110 degrees F. The grease in the deep fryer was black. These failures could place the residents at risk of foodborne illnesses. Findings include: During an observation and interview on 06/05/23 at 9:04 AM surveyor entered the kitchen and noted the calendar log for the dish machine had not been completed for 06/05/23, and the sanitizer bottle attached to the dish machine was empty. Dietary Staff F was standing at the dish machine, and it was running washing dishes. […]

• No harm, potential for more than minimal, widespreadF812Apr 27, 2022

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure all food items were labeled and dated in the freezer and two refrigerators. The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. These failures could place residents at risk of foodborne illness. Findings included: Record review of a week 3 regular menu indicated for the evening meal on Monday black bean soup, egg salad sandwich, beet and onion salad, winter fruit cup, milk, iced tea and oil and vinegar dressing. […]

• No harm, potential for more than minimal, widespreadF908Apr 27, 2022

  Based on observation, interview and record review the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness. Findings included: Record review of a Refrigerator /Freezer Temperature Log dated April indicated Unit #3 (Refrigerator #2) on April 25 PM the refrigerator temperature was 55 degrees. The entry was initialed by the Dietary Supervisor. On April 26 AM the temperature for Unit #3 (Refrigerator #2) was 60 degrees. […]