Monarch Springs Wellness & Rehabilitation

Name: Monarch Springs Wellness & Rehabilitation
Address: 894 LELAND AVENUE, University City, MO, 63130, US
Telephone: 3147264767

894 Leland Avenue, University City, MO 63130 · St. Louis County · 119 certified beds · avg 55 residents/day · certified since Jul 20, 2009

Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

2.49

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Jan 31, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 20, 2025 (Past Non-Compliance)

All citations in the current public record (38)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 7, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 7, 2026	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 7, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
May 7, 2026	D · Potential for harm, one-off	The facility did not make sure a transfer or discharge met the resident's needs and preferences, or did not properly prepare the resident to leave safely. · from a complaint
May 7, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
May 7, 2026	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
May 7, 2026	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 7, 2026	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 7, 2026	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
May 7, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 7, 2026	C · Minimal risk, facility-wide	The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss.
Mar 20, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 31, 2025	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Jan 31, 2025	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 12, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 12, 2024	F · Potential for harm, facility-wide	The facility has more than 120 beds but did not hire a qualified full-time social worker as required.
Jul 12, 2024	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 12, 2024	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 12, 2024	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 12, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jul 12, 2024	E · Potential for harm, repeated	The facility did not dispose of garbage and refuse properly.
Jul 12, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 12, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jul 12, 2024	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jul 12, 2024	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
May 2, 2024	D · Potential for harm, one-off	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint
May 2, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
May 2, 2024	D · Potential for harm, one-off	The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint
Dec 9, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 9, 2022	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 9, 2022	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 9, 2022	E · Potential for harm, repeated	The facility has more than 120 beds but did not hire a qualified full-time social worker as required.
Dec 9, 2022	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 9, 2022	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Dec 9, 2022	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Dec 9, 2022	D · Potential for harm, one-off	The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require.
Dec 9, 2022	D · Potential for harm, one-off	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices.
Dec 9, 2022	C · Minimal risk, facility-wide	The facility did not make sure its staff were vaccinated for COVID-19 in accordance with the federal requirements in effect at the time.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 11).

Year	Citations	Serious (G–L)	Worst severity that year
2022	10	0	F
2024	14	0	F
2025	2	1	G ▲
2026	12	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Missouri avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.49	3.66	3.95	bottom 13% in Missouri; bottom 3% in the U.S.
Registered Nurse hours	0.28	0.49	0.69	bottom 23% in Missouri; bottom 7% in the U.S.
Weekend total nurse staffing	2.18	3.22	3.50	bottom 13% in Missouri; bottom 3% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.17	0.33	0.48	bottom 20% in Missouri; bottom 8% in the U.S.
Total nursing staff turnover (%)	0.0	56.0	45.8	—
RN turnover (%)	0.0	47.8	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.87, RN 0.32, weekend 2.52. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Amber HC Trust	Organization	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Arches Healthcare LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	05/01/2025
First Sweetzer Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Garetz, David	Individual	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Kaplan, Esther	Individual	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Lucent Advisors LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Rimpau Holdings Trust	Organization	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
Sasem Investments LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	05/01/2025
894 Leland Ave Mo LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2025
Arches Healthcare LLC	Organization	5% or Greater Security Interest	NOT APPLICABLE	05/01/2025
Bankwell Bank	Organization	5% or Greater Security Interest	NOT APPLICABLE	05/01/2025
Campbell, Kevin	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Campbell, Kevin	Individual	ADP of the SNF	NOT APPLICABLE	08/05/2025
Davidovich, Niv	Individual	Trustee of the SNF	NOT APPLICABLE	05/01/2025
Forvis Mazars LLP	Organization	Operational/Managerial Control	NOT APPLICABLE	06/01/2023
Forvis Mazars LLP	Organization	ADP of the SNF	NOT APPLICABLE	06/01/2023
Gao, Shawn	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Gao, Shawn	Individual	ADP of the SNF	NOT APPLICABLE	08/05/2025
Garetz, David	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025
Gurwitz, Solomon	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What alternatives do you try before using bed rails, and how do you involve families in that decision?"
"Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
U-City Forest Manor	1.2 mi	Saint Louis, MO	★☆☆☆☆	2/5
Delhaven Manor	1.5 mi	Saint Louis, MO	★★★☆☆	2/5
Normandy Nursing Center	1.9 mi	Saint Louis, MO	★☆☆☆☆	2/5	abuse
Oak Park Care Center	2.1 mi	Saint Louis, MO	★★★☆☆	4/5
Barnes-Jewish Extended Care	2.4 mi	Saint Louis, MO	★★★☆☆	3/5
Bernard Care Center	3.2 mi	Saint Louis, MO	★☆☆☆☆	2/5
Grand Manor Health Care Center	4.1 mi	Saint Louis, MO	★☆☆☆☆	2/5
Amberwood Estates Nursing and Rehabilitation	4.1 mi	Saint Louis, MO	★☆☆☆☆	2/5
McKnight Place Extended Care	4.1 mi	Saint Louis, MO	★★★★☆	4/5
Lutheran Convalescent Home	4.3 mi	Webster Groves, MO	★★★★★	4/5
Heritage Care Center	4.3 mi	Saint Louis, MO	★☆☆☆☆	1/5	abuseSFF
St Johns Place	4.3 mi	Saint Louis, MO	★☆☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in University City →

Facility data as of CMS processing date 2026-08-01. CCN 265831.

The Care File

Visit checklist — Monarch Springs Wellness & Rehabilitation

894 Leland Avenue, University City, MO 63130 · 3147264767

Health inspection rating 3/5 · CMS overall 2/5· Fines (3y): $0

Most serious findings on record:

▲ Jan 31, 2025 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "Before a resident is discharged or transferred, how do you make sure the new place can actually meet their needs?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
☐ "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 265831 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)