Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Grove Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, dependent on staff for bed mobility, was not adequately supervised during incontinent care. A CNA attempted to turn the resident without first pulling her closer, resulting in the resident rolling off the bed and sustaining multiple femur fractures. Staff interviews and record reviews indicated the care plan called for one-person assistance, and the incident occurred while the resident was on an air mattress with the bed at its highest position.
The facility failed to store food according to professional standards, with dry storage items improperly stored and frozen foods unlabeled and exposed. Observations revealed flour and salt stored with scoops inside containers, and several freezer items, including okra and squash, were improperly labeled or sealed. Interviews with the dietary manager and administrator confirmed expectations for proper food storage to prevent foodborne illness.
The facility failed to provide timely incontinent care for two residents with cognitive impairments, leading to prolonged periods of being soiled. Additionally, a resident with severe cognitive impairment did not receive proper denture care, resulting in discolored and crusty dentures. Staff interviews and observations confirmed these deficiencies, highlighting a lack of adherence to care plans and oversight by nursing management.
The facility failed to ensure safe storage of food in residents' personal refrigerators, with observations revealing unlabeled and undated items, including spoiled food. A resident with cognitive impairment had a refrigerator containing an unknown food item with a green substance, while another resident's refrigerator had fruit with fuzzy growth. The housekeeping supervisor was responsible for monthly cleaning, but lacked a set schedule or documentation. The facility's policy required labeling and discarding food after seven days.
A facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions during incontinent care for three residents. Staff members did not perform hand hygiene between glove changes and improperly handled soiled linen, despite being trained on these protocols. These lapses in protocol could potentially lead to the spread of infections.
The facility failed to maintain a safe environment by not properly handling and inspecting Hoyer lift slings, leading to potential accident hazards. A resident with muscle weakness and hypertension was observed using a worn sling, and staff interviews revealed a lack of awareness of manufacturer guidelines for sling maintenance. The facility's policy was not followed, as compromised slings were not removed from service.
The facility failed to ensure that the emergency call light systems in the bathrooms of two residents were equipped with cords long enough to be reachable from the floor. A resident with severe impaired cognition and a history of falls had a call light with a metal string only four inches long, while another resident requiring partial assistance with toileting had a call light string two feet short of reaching the floor. Staff interviews revealed a lack of awareness and formal procedures for checking the functionality and safety of call light systems.
Failure to Provide Adequate Supervision During Incontinent Care Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including dementia, hemiplegia, hemiparesis, and a high risk for falls, was not adequately supervised during incontinent care. The resident was dependent on staff for bed mobility and required total assistance for activities of daily living. The care plan and electronic health record indicated the resident was a one-person assist for bed mobility, and staff were trained accordingly. During the incident, a CNA attempted to provide incontinent care by turning the resident onto her weak side without first pulling her closer, resulting in the resident rolling off the bed. The CNA reported that she was unable to prevent the resident from falling despite holding onto her leg and arm as the resident rolled off the bed. The resident sustained a comminuted distal left femur fracture with apex posterior angulation and mild impaction, as well as a non-displaced fracture of the right distal femoral shaft. The incident report and nurse notes confirmed that the resident complained of severe pain and had visible injuries following the fall. The resident was transported to the hospital for evaluation and treatment of her injuries. Interviews with staff and review of records revealed that the resident's bed was set at its highest position and she was on an air mattress, which may have contributed to the fall. The CNA involved stated she did not pull the resident toward her before turning, citing lack of space, and believed it would not have made a difference. The DON confirmed that staff are expected to pull residents toward them before rolling and acknowledged that failure to do so could result in falls and injuries. The care plan at the time of the incident did not specify a need for two-person assistance for bed mobility, and other CNAs reported no difficulty providing care with one-person assistance.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed during a survey of the kitchen. Specifically, dry storage items were improperly stored, with flour and salt kept in containers with scoops inside, and the salt container lacked a label and date. In the freezer, several items were found improperly stored: a bag of okra was left in an unsealed bag within an open box, squash was stored in a box without any label or date, and a leftover pecan pie dated from nearly a month prior was uncovered in a pie tin. Interviews with the dietary manager and the administrator revealed that both expected the dietary staff to follow policies and regulations regarding food labeling and storage to prevent foodborne illness. The facility's food storage policy mandates the use of airtight containers or bags for opened food packages, accurate labeling with item names and dates, and proper securing and labeling of any food items removed from their original packaging. The observed deficiencies in food storage practices could potentially lead to food contamination and foodborne illness among residents.
Deficiencies in Personal Hygiene and Denture Care
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for three residents, leading to deficiencies in care. Resident #12, a male with mild cognitive impairment, was not provided timely incontinent care. Despite being frequently incontinent and requiring maximal assistance, observations revealed that he remained soiled with urine and feces for extended periods on 7/22/2024. Interviews with the resident and staff confirmed that care was not provided every two hours as required, which could lead to skin breakdown. Similarly, Resident #48, a male with hemiplegia and moderately impaired cognition, was also not provided timely incontinent care. He was observed to be soiled with urine and had an odor, indicating a lack of care since before breakfast. Staff interviews revealed that the resident was not changed as per the care plan, which required checks every two hours. This neglect in providing care could result in skin breakdown and infections. Resident #35, a female with severe cognitive impairment and no natural teeth, did not receive proper denture care. Despite having full dentures, the CNA responsible for her care was unaware and only assisted with brushing, leading to the resident's dentures being discolored and crusty. The facility's documentation did not include interventions for denture care, and the oversight by the DON and ADON was insufficient to ensure proper care was provided.
Deficiency in Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents' food items in personal refrigerators, as per their policy. During observations, it was found that the personal refrigerators of three residents contained unlabeled and undated food items. Specifically, Resident #43's refrigerator had an unlabeled container with an unknown food item covered in a green, powdery substance. Similarly, the refrigerators of Resident #5 and Resident #51 contained a clear container of cut fruit with white, grey fuzzy growth and a zipper bag of unlabeled and undated fried meat. Resident #5, a cognitively intact individual with a BIMS score of 15, reported that her family brought her food, which she stored in her personal refrigerator. She mentioned that she sometimes cleaned the refrigerator herself and that staff would assist if requested. Resident #43 and Resident #51, both with severe cognitive impairments and BIMS scores of 6 and 5 respectively, required assistance with eating and had poor decision-making abilities. The presence of spoiled and unlabeled food items in their refrigerators posed a risk of foodborne illnesses. Interviews with facility staff revealed that the housekeeping supervisor was responsible for cleaning out residents' personal refrigerators, which was done approximately once a month without a set schedule or documentation. The administrator acknowledged the issue of unlabeled and expired items in personal refrigerators and noted that families often did not label or remove expired foods. The facility's policy required housekeeping staff to clean refrigerators monthly and for families to label food with the resident's name, room number, and date, discarding items after seven days.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and failure to follow enhanced barrier precautions during incontinent care. Three residents were directly affected by these lapses in protocol. Resident #12, a male with mild cognitive impairment, was subjected to care by CNA A, who did not perform hand hygiene between glove changes and improperly handled soiled linen by carrying it openly down the hallway without bagging it first. Resident #30, a female with moderate cognitive impairment and a stage 2 sacral pressure ulcer, was on enhanced barrier precautions due to the risk of spreading multi-drug resistant organisms. CNA C failed to adhere to these precautions by not wearing a gown during care and neglecting to sanitize her hands between glove changes. Despite being trained on these protocols, CNA C admitted to forgetting the necessary steps during the care process. Resident #259, who was dependent on staff for toileting hygiene, received care from CNA E, who did not wash her hands between handling soiled and clean briefs. This oversight occurred despite CNA E's acknowledgment of the correct procedure and her training in infection control. The Director of Nursing, Assistant Director of Nursing, and Infection Preventionist were responsible for overseeing infection control measures, which were not followed, potentially leading to the spread of infections.
Failure to Maintain Safe Hoyer Lift Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not developing and implementing a policy and procedure for the proper handling and inspection of Hoyer lift slings. Observations revealed that the slings in use were faded, frayed, and had illegible care labels, indicating wear and potential safety risks. The facility did not remove these compromised slings from service, which could result in falls and injuries during mechanical lift transfers. Resident #18, a female with muscle weakness and hypertension, was observed using a Hoyer lift sling that was visibly worn and dated back to 2018. Interviews with staff, including a CNA, ADON, and DON, revealed a lack of awareness regarding the manufacturer's guidelines for sling maintenance, which include removing slings with color changes or illegible labels. The facility's policy for mechanical lifts was not followed, as it required slings to be in good working condition, aligning with the manufacturer's safety recommendations.
Inadequate Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the emergency call light systems in the bathrooms of two residents were equipped with cords long enough to be reachable from the floor. This deficiency was identified during observations and interviews with residents and staff. Resident #9, a female with severe impaired cognition and a history of falls, had a bathroom call light with a metal string protruding only four inches from the wall, making it inaccessible from the floor. Resident #19, a male with intact cognition but requiring partial assistance with toileting, had a call light string that was two feet short of reaching the floor. Both residents were at risk of being unable to call for help in the event of a fall. Interviews with staff revealed a lack of awareness and formal procedures for checking the functionality and safety of call light systems. A housekeeper noticed the issue but did not initially recognize it as a problem, although she later reported it to the Maintenance Director. The Maintenance Director acknowledged the importance of having call light strings reach the floor but admitted there was no formal checklist for ensuring safety items in rooms were regularly checked. The facility's policy on answering call lights emphasized the need to meet residents' needs, but the deficiency indicated a failure to adhere to this policy.
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What surveyors actually found near you
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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 Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Center | 0 mi | ★★★★★ | 0 | 0 |
| Focused Care Of Center | 1.6 mi | ★★★★★ | 3 | 0 |
| Stonecreek Nursing & Rehabilitation | 18.6 mi | ★★★★★ | 6 | 0 |
| Avir At San Augustine | 18.8 mi | ★★★★★ | 4 | 0 |
| Colonial Pines Healthcare Center | 19.1 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.