Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine View Manor Inc during CMS and state inspections, most recent first.
Two cognitively intact residents engaged in a verbal argument after one made a rude, profane comment to a staff member and threatened to hit the other resident. One resident was taken back to their room while the other remained near the nurse’s station; about ten minutes later, the resident in a wheelchair went down the hall, turned into the other resident’s room despite an LPN telling them not to, and a physical struggle occurred, with both ending up on the floor. One resident sustained a scraped knee, a skin tear to the elbow, and a contusion with a large bruise and pain to the left ribs and chest wall, later confirmed in ER records. Staff acknowledged that resident‑to‑resident altercations are considered abuse and that 15‑minute checks are typically used afterward, but in this case no formal 15‑minute checks or one‑on‑one observation were implemented, and there was no formal protocol or documentation tool specifying or recording the frequency of monitoring, leading to the cited deficiency.
The facility failed to adhere to safe food storage practices, as dented and unlabeled canned foods were found in the dry storage area. Despite having a policy for food receiving and storage, there was no specific guideline for handling dented cans. Staff interviews revealed inconsistent practices in inspecting and storing deliveries, leading to the presence of 36 compromised cans, which posed potential contamination risks.
A facility failed to ensure proper infection control during medication administration and oxygen supply management. A CMT did not wear gloves or wash hands between fingerstick blood sugar checks for two residents with diabetes, contrary to facility policy. Additionally, a resident's oxygen tubing was not consistently dated or stored in a bag, as required. The facility's policies were not followed, leading to deficiencies in infection control practices.
A resident with COPD and non-Alzheimer's dementia was not assessed for self-administration of medication, despite expressing a desire to do so. The facility's policy requires an assessment by the interdisciplinary team to ensure safety and appropriateness, but no such evaluation was conducted. Interviews with staff revealed a lack of awareness regarding the necessity of this assessment, leading to a deficiency in care.
A facility failed to include a resident's supplemental oxygen usage in their care plan, despite having active orders for oxygen due to conditions like pneumonia and heart failure. Interviews with staff confirmed that care plans should address oxygen use, but this was not reflected in the resident's care plan, leading to a deficiency.
A resident with COPD experienced shortness of breath after physical activity, prompting a CNA to adjust the oxygen concentrator to 3 liters per minute, despite not being licensed to do so. Facility staff confirmed that only licensed personnel should adjust oxygen settings, and the CNA failed to report the resident's condition to a nurse.
A resident with a history of hypoxemia and other conditions required supplemental oxygen therapy, but the facility failed to specify the liters per minute (L/min) parameters in the orders. Staff monitored the resident's blood oxygen saturation and adjusted the oxygen flow, but noted the absence of specific L/min guidelines. The deficiency was identified as a failure to include these parameters, which are essential for proper respiratory care.
A resident with hypertension and severe cognitive impairment received metoprolol tartrate despite not meeting the prescribed blood pressure parameters. The facility's staff failed to document the resident's heart rate and administered the medication multiple times when it should have been held. Interviews with staff revealed a lack of adherence to physician's orders, leading to a significant medication error.
A resident with COPD and intact cognition was allowed to self-administer Flonase nasal spray, but the facility failed to ensure it was stored securely. The medication was left on the dresser, accessible to others, against the facility's policy. Staff interviews revealed inconsistencies in understanding the storage policy, with expectations ranging from bedside tables to bathroom cabinets.
The facility failed to ensure nurse aides received the required 12 hours of in-service training per year, as two CMTs did not meet this requirement. Their training records lacked sessions on dementia management, and the facility acknowledged missing records. A new Staff Development Director had been hired but had not yet started.
Failure to Prevent and Adequately Monitor Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident‑to‑resident physical altercation following a verbal confrontation. The facility had policies on Abuse and Neglect and Resident‑to‑Resident Altercations that required staff to prohibit and prevent abuse, monitor residents for aggressive or inappropriate behavior toward others, review events with nursing leadership, and document interventions and their effectiveness. On the day of the incident, two cognitively intact residents engaged in a verbal argument at the nurse’s station after one resident made a rude, profane comment to a dietary aide about grapes. Another resident, who was independent with activities of daily living, heard the remark and told the first resident not to speak to staff that way. The first resident became angry and responded aggressively, including stating that he/she was going to hit the other resident one of these days. Following this verbal altercation, staff assisted one resident back to his/her room while the other remained seated near the nurse’s station with staff nearby. Approximately ten minutes later, staff who had been sitting with the resident near the nurse’s station went outside on break. During this period, the resident who had remained near the nurse’s station proceeded down the hallway in a wheelchair past the other resident’s room, then turned around and entered that room despite being told by an LPN not to go into the room. When the LPN arrived at the room, both residents were found on the floor. Accounts from the residents differed as to who initiated the physical contact, but both described a physical struggle in which they shoved each other and fell, with one resident reporting having lunged and the other reporting reaching toward the first resident. As a result of the altercation, one resident sustained physical injuries including a scraped left knee, a skin tear to the left elbow, and a red mark and contusion to the left rib and left chest wall, with pain to the left ribs and left knee documented in emergency room discharge instructions. Observation later showed a grapefruit‑sized bruise on the left rib area. Staff interviews confirmed that resident‑to‑resident physical altercations were considered abuse under facility practice and that typically 15‑minute checks were done after such incidents. In this case, neither resident was placed on one‑on‑one observation or formal 15‑minute checks after the altercation, and there was no formal protocol or documentation tool used to specify or record how often the residents should be monitored, despite instructions to staff to keep a close watch on them. This sequence of events and lack of structured monitoring following the initial verbal threat and subsequent altercation led to the cited deficiency for failure to protect a resident from abuse.
Failure to Maintain Safe Food Storage Practices
Penalty
Summary
The facility failed to maintain professional standards in food storage and handling, as evidenced by the presence of dented canned foods in the dry storage area. Observations revealed several compromised cans, including unlabeled and dented cans of various food items, which were not segregated from the usable stock. The facility's policy on food receiving and storage required safe handling practices, but there was no specific policy addressing dented canned foods. Interviews with staff, including the Certified Dietary Manager (CDM) and dietary aides, indicated a lack of consistent procedures for handling and removing dented cans, leading to their presence in the storage area. The CDM acknowledged the risks associated with dented cans, such as potential contamination and illness, but the facility did not have a designated area for storing such items. Staff interviews revealed inconsistent practices in inspecting and handling deliveries, with some staff unaware of the proper procedures for dealing with compromised cans. The Administrator and Director of Nursing Services (DNS) were also interviewed, with the DNS unaware of the risks posed by dented cans. Ultimately, 36 compromised cans were removed from the storage area, highlighting the facility's failure to adhere to safe food handling standards.
Infection Control Deficiencies in Medication Administration and Oxygen Supply Management
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, specifically during fingerstick blood sugar checks. A Certified Medication Technician (CMT) did not wear gloves while performing fingerstick blood sugar checks for two residents, one with type one diabetes mellitus and another with type two diabetes mellitus. The CMT also failed to wash hands between residents, which was against the facility's policy that required wearing gloves and hand hygiene when there was potential contact with blood. The CMT admitted to forgetting to wear gloves and not washing hands, and both the Director of Nursing Services (DNS) and the Administrator confirmed that the facility's policy was not followed. Additionally, the facility did not properly label and store oxygen supplies for a resident who used supplemental oxygen at night. The resident's oxygen tubing and nasal cannula were observed lying on the bed and hanging on the bed rail without being stored in a bag or dated, contrary to the facility's expectations. Interviews with staff revealed that night shift staff were responsible for changing and dating the oxygen tubing weekly, while day shift staff were to ensure the tubing remained clean. However, the tubing was not consistently dated or stored in a bag as required. The Administrator and other staff members confirmed that the facility's policy was for oxygen tubing to be dated and stored in a bag when not in use. Despite these expectations, observations showed that the policy was not consistently followed, leading to a deficiency in infection control practices related to the storage and labeling of oxygen supplies.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, who expressed a desire to self-administer medication, was assessed to determine if it was clinically appropriate for them to do so. The facility's policy on self-administration of medications requires an interdisciplinary team to assess a resident's mental and physical abilities to determine if self-administration is safe and appropriate. However, in the case of the resident with a history of chronic obstructive pulmonary disease and non-Alzheimer's dementia, no such assessment was conducted. The resident had a physician's order to keep Flonase at their bedside, but there was no documented evidence of an assessment for self-administration. Interviews with facility staff, including the MDS Coordinator, a registered nurse, and the Director of Nursing Services, revealed a lack of awareness and understanding of the requirement for an assessment before allowing a resident to self-administer medication. The MDS Coordinator believed that a physician's order was sufficient for a resident to keep medication at the bedside, while the RN was unaware of the need for an assessment. The Director of Nursing Services stated that staff should ensure a resident is capable of self-administering medication and document the assessment in the electronic medical record, but this was not done for the resident in question.
Deficiency in Care Plan for Supplemental Oxygen Use
Penalty
Summary
The facility failed to develop a care plan addressing the use of as-needed supplemental oxygen for a resident with a history of pneumonia and heart failure. The resident was admitted on June 19, 2023, and had active orders for two liters of supplemental oxygen via nasal cannula as needed for shortness of air and at bedtime for hypoxia. However, the resident's care plan did not include any information regarding the supplemental oxygen usage prior to May 31, 2024, which was during the survey. Interviews conducted during the survey revealed that the facility's Registered Nurse and Administrator both acknowledged that care plans should address a resident's use of oxygen, including the ordered flow rate, usage parameters, and whether it was used continuously or as needed. Despite these expectations, the care plan for the resident in question did not reflect these details, leading to the identified deficiency.
Unlicensed Personnel Adjusted Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that only licensed personnel adjusted the flow rate on an oxygen concentrator for a resident with chronic obstructive pulmonary disease (COPD). The resident, who had intact cognition and was receiving oxygen therapy, was observed with an oxygen concentrator set to deliver 2.5 liters per minute. After experiencing shortness of breath following physical activity, the resident activated their call light. A Certified Nurse Aide (CNA) responded and adjusted the oxygen concentrator to deliver 3 liters per minute, despite not being licensed to administer medications or adjust oxygen settings. Interviews with facility staff revealed that the CNA was aware that supplemental oxygen is considered a medication and that she was not authorized to change the oxygen concentrator settings. The Director of Nursing Services (DNS) and other staff confirmed that CNAs were not permitted to adjust oxygen concentrators and should report any issues to a nurse. The DNS acknowledged that the CNA did not report the resident's shortness of breath or the adjustment made to the oxygen concentrator. The facility's policy required that only licensed personnel administer medications, including oxygen therapy, as per physician orders.
Deficiency in Oxygen Therapy Due to Lack of Dose Parameters
Penalty
Summary
The facility failed to specify dose parameters for supplemental oxygen for a resident, leading to a deficiency in respiratory care. The resident, who had a medical history of hypoxemia, dystonia, torticollis, and pneumonia, was admitted to the facility and required oxygen therapy. The care plan indicated the use of humidified supplemental oxygen via nasal prongs at 2 liters continuously at night and as needed during the day. However, the order summary report for the resident's supplemental oxygen did not specify the liters per minute (L/min) parameters, only indicating that the oxygen should maintain blood oxygen saturation levels above 91%. Observations and interviews revealed that the resident's nasal cannula was often askew, and the oxygen concentrator was set at 2 L/min. Staff members, including a CNA and RN, were aware of the need to monitor the resident's blood oxygen saturation levels and adjust the oxygen flow as necessary. However, they noted the absence of specific L/min parameters in the orders, which should have been included to guide the administration of oxygen therapy. The RN mentioned that she would start with 2 L/min in the absence of specific parameters and monitor the resident's condition. Interviews with various staff members, including the DNS and the facility's administrator, confirmed that supplemental oxygen orders should include L/min parameters. The DNS acknowledged the issue and stated that they were awaiting a call back from the physician to update the order with the necessary parameters. The deficiency was identified as a failure to include L/min parameters in the supplemental oxygen orders, which is essential for ensuring proper respiratory care for the resident.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of metoprolol tartrate, a medication used for high blood pressure. The resident, who had a history of essential hypertension and severe cognitive impairment, was admitted with a physician's order for metoprolol tartrate 25 mg twice daily. The order included specific parameters to hold the medication if the resident's systolic blood pressure was below 120 mmHg, diastolic blood pressure was less than 60 mmHg, or if the heart rate was less than 60 beats per minute. However, the Medication Administration Record (MAR) showed that staff administered the medication multiple times despite the resident's blood pressure readings not meeting the required parameters, and without documenting the resident's heart rate. Interviews with Certified Medication Technicians (CMTs) revealed that they did not follow the physician's orders. CMT #4 and CMT #10 acknowledged that the resident's pulse was not documented, and the medication was given even when blood pressure parameters were not met. CMT #11 admitted to administering the medication without checking the resident's pulse and overlooking the blood pressure parameters. Registered Nurse (RN) #5 confirmed that the medication should not have been given when the systolic blood pressure was below 120 mmHg and expressed concern that the CMTs did not report the low blood pressure readings. The Consultant Pharmacist (CP) and the Director of Nursing Services (DNS) both stated that the medication should have been held when the parameters were not met. The DNS was unaware that the medication was administered against the parameters and that the heart rate was not documented on the MAR. The Administrator expected the physician's orders to be followed and for the physician to be notified if the parameters were not met. The failure to adhere to the physician's orders and the lack of proper documentation led to the significant medication error.
Failure to Securely Store Self-Administered Medication
Penalty
Summary
The facility failed to ensure the safe storage of medication for a resident who was permitted to self-administer Flonase nasal spray. The resident, who had intact cognition and a medical history of chronic obstructive pulmonary disease, had a physician's order allowing them to keep the Flonase at their bedside. However, the medication was observed on the resident's dresser, accessible to others, contrary to the facility's policy requiring self-administered medications to be stored in a secure place not accessible by other residents. Interviews with facility staff, including a CNA, CMT, RN, and the Director of Nursing Services, revealed inconsistencies in the understanding and implementation of the facility's policy on medication storage. The CNA and CMT acknowledged the medication was kept on the dresser, while the RN mentioned it should be stored on or in the bedside table. The Director of Nursing Services expected medications to be stored in a bathroom cabinet, and the Administrator expected them to be out of sight. The resident confirmed that no instructions were provided by the staff on how to store the medication securely.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training per year, as mandated by the Facility Assessment Tool. This deficiency was identified through interviews, record reviews, and an examination of the Facility Assessment Tool. Specifically, two Certified Medication Technicians (CMTs), hired in 2018 and 2019 respectively, did not meet the training requirements. CMT #3 attended only four in-services from June 2022 to June 2023, none of which included dementia management training. Similarly, CMT #10 attended only four in-services from December 2022 to December 2023, also lacking dementia management training. The records did not specify the number of in-service hours awarded for each session attended by these CMTs. The Administrator acknowledged the potential absence of complete in-service training records during an interview. It was noted that the facility had recently hired a full-time Staff Development Director (DSD), although the DSD had not yet commenced work at the facility. This situation indicates a lapse in maintaining adequate training records and ensuring compliance with the required in-service training hours, particularly in critical areas such as dementia management and abuse prevention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stanberry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Worth County Convalescent Center | 19.5 mi | ★★★★★ | 9 | 0 |
| Maryville Living Center | 19.7 mi | ★★★★★ | 5 | 0 |
| Village Care Center Inc | 19.7 mi | ★★★★★ | 1 | 0 |
| Parkdale Manor Health & Rehabilitation | 20.4 mi | ★★★★★ | 1 | 0 |
| Abundant Acres Care And Rehab | 23 mi | ★★★★★ | 42 | 2 |
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