Pine Grove Manor
4359 Taft Avenue, Saint Louis, MO 63116 · St. Louis City County · 77 certified beds · avg 52 residents/day · certified since May 1, 2009
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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)
▲ Immediate jeopardy, one-off · Dec 22, 2025 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 23, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Apr 3, 2024 · F-0689
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 (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 7, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 1, 2026 · 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.
▲ Actual harm, one-off · Oct 13, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: Oct 3, 2023 (Past Non-Compliance)
All citations in the current public record (35)
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 |
|---|---|---|
| Jul 1, 2026 | ▲ 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 |
| Mar 13, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Mar 13, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 13, 2026 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Mar 13, 2026 | 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. |
| Mar 13, 2026 | E · Potential for harm, repeated | 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. |
| Mar 13, 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. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 13, 2026 | D · Potential for harm, one-off | 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. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Mar 13, 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. |
| Mar 13, 2026 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · from a complaint |
| Dec 22, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Dec 22, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 22, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Dec 22, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 3, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 3, 2024 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 3, 2024 | E · Potential for harm, repeated | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. |
| Apr 3, 2024 | 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. |
| Apr 3, 2024 | 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. |
| Apr 3, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Nov 29, 2023 | 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 |
| Oct 13, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jun 10, 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. |
| Jun 10, 2022 | 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. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Jun 10, 2022 | C · Minimal risk, facility-wide | The facility did not properly protect the personal money residents deposited with it for safekeeping. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 6 | 0 | F |
| 2023 | 2 | 1 | G ▲ |
| 2024 | 6 | 1 | K ▲ |
| 2025 | 4 | 1 | J ▲ |
| 2026 | 17 | 1 | G ▲ |
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)
2 fines totaling $31,665, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Dec 22, 2025 | Fine | $9,510 |
| Apr 3, 2024 | Fine | $22,155 |
| Apr 3, 2024 | Payment Denial | 13 days from May 15, 2024 |
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) | 2.68 | 3.66 | 3.95 | bottom 15% in Missouri; bottom 6% in the U.S. |
| Registered Nurse hours | 0.32 | 0.49 | 0.69 | bottom 30% in Missouri; bottom 12% in the U.S. |
| Weekend total nurse staffing | 2.39 | 3.22 | 3.50 | bottom 17% in Missouri; bottom 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.33 | 0.48 | bottom 41% in Missouri; bottom 19% 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 3.14, RN 0.37, weekend 2.79. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| 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 |
| Gurwitz, Solomon | Individual | Direct Ownership Interest | NOT APPLICABLE | 03/01/2024 |
| 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 |
| 4359 Taft Ave Mo LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2025 |
| Bankwell Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 05/01/2025 |
| Brencick, Mark | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2025 |
| Brencick, Mark | Individual | ADP of the SNF | NOT APPLICABLE | 08/11/2025 |
| Davidovich, Niv | Individual | Trustee of the SNF | NOT APPLICABLE | 05/01/2025 |
| Esdov Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/11/2025 |
| 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 | 08/11/2025 |
| Garetz, David | 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.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "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 |
|---|---|---|---|---|---|
| Lansdowne Village | 0.2 mi | Saint Louis, MO | ★☆☆☆☆ | 2/5 | |
| Magnolia Wellness Center | 1.4 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | abuse |
| Beauvais Rehab and Healthcare Center | 2.0 mi | Saint Louis, MO | ★☆☆☆☆ | 2/5 | abuse |
| Carrie Elligson Gietner Health Care Center | 2.1 mi | Saint Louis, MO | ★☆☆☆☆ | 1/5 | |
| St Louis Altenheim | 2.2 mi | Saint Louis, MO | —/5 | ||
| Life Care Center of St Louis | 3.2 mi | Saint Louis, MO | ★★★★☆ | 3/5 | |
| Mary, Queen and Mother Center | 3.4 mi | Shrewsbury, MO | ★★☆☆☆ | 2/5 | |
| Oak Park Care Center | 3.4 mi | Saint Louis, MO | ★★★☆☆ | 4/5 | |
| Lutheran Convalescent Home | 3.6 mi | Webster Groves, MO | ★★★★★ | 4/5 | |
| Lemay Nursing | 3.7 mi | Saint Louis, MO | ★★☆☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 265828.