Pine Grove Manor

• Fine

  CMS changed the fine from December 22, 2025 from $9,510 to $6,182.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

64 of 486 Missouri homes (13%) got a citation at the actual harm level in 2026.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS has cited this home for F0689 3 times since 2023.

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• Staffing

  Total nurse staffing reported to CMS went from 3.8 to 3.4 hours per resident per day.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0658. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on March 28, 2026.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on March 28, 2026.

• Citation F0679. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on March 28, 2026.

  CMS has cited this home for F0679 2 times since 2024.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on April 29, 2026.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on March 28, 2026.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on March 28, 2026.

  CMS has cited this home for F0812 3 times since 2022.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on March 28, 2026.

  CMS has cited this home for F0584 2 times since 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 28, 2026.

  CMS has cited this home for F0684 2 times since 2025.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on March 28, 2026.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on March 28, 2026.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on March 28, 2026.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on March 28, 2026.

• Citation F0732. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on March 28, 2026.

• Citation F0740. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  CMS lists it as corrected on March 28, 2026.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on March 28, 2026.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on March 28, 2026.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Name

  CMS lists a new legal business name for this home.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

65 of 486 Missouri homes (13%) got a citation at the immediate jeopardy level in 2025.

• Citation F0678. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on December 23, 2025.

  CMS has cited this home for F0678 2 times since 2022.

• Citation F0760. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on December 23, 2025.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on December 23, 2025.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 23, 2025.

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CMS fine of $6,182 on December 22, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Name

  CMS lists a new legal business name for this home.

• Staffing

  Total nurse staffing reported to CMS went from 3.4 to 2.4 hours per resident per day.

• Fire safety citation

  CMS removed citation K0161 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0211 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0363 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0500 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0511 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0712 from the fire safety inspection on April 3, 2024.

• Fire safety citation

  CMS removed citation K0741 from the fire safety inspection on April 3, 2024.

• Ownership

  CMS lists this home under a new chain.

• Name

  CMS lists a new name for this home. It was AVALON GARDEN.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Fine

  CMS changed the fine from April 3, 2024 from $34,085 to $22,155.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

CMS stopped payment for new admissions from May 15, 2024, for 13 days.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

70 of 486 Missouri homes (14%) got a citation at the immediate jeopardy level in 2024.

• Citation F0689. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 7, 2024.

• Citation F0679. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on May 7, 2024.

• Citation F0680. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure the activities program is directed by a qualified professional.

  CMS lists it as corrected on May 7, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 28, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 7, 2024.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on May 7, 2024.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on May 7, 2024.

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CMS fine of $22,155 on April 3, 2024.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 6, 2023.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

35 of 486 Missouri homes (7%) got a citation at the actual harm level in 2023.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on October 3, 2023.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on July 20, 2022.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on July 20, 2022.

• Citation F0678. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

  CMS lists it as corrected on July 20, 2022.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on July 20, 2022.

• Citation F0909. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

  CMS lists it as corrected on July 20, 2022.

• Citation F0570. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Assure the security of all personal funds of residents deposited with the facility.

  CMS lists it as corrected on July 29, 2022.

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