Monterey Park Rehab: Fall Notification Failure - MO
He had just been lowered to the floor of a shower room at Monterey Park Rehabilitation & Health Care Center after a fall. His knee was fractured, though nobody at the facility knew that yet. And before the nurse assigned to his care had gotten around to contacting his family, the resident reached them on his own, while they were already out at a doctor's appointment that morning.
His family member took him to the emergency room. The ER found a closed fracture of the right tibial plateau, the top surface of the shin bone where it meets the femur to form the knee joint. It is a weight-bearing surface. The injury was real, and it was serious.
State inspectors cited the facility following a complaint investigation completed in November 2025. The violation was tagged under federal notification requirements, with a finding of minimal harm or potential for actual harm affecting a small number of residents.
The shower aide, identified in inspection records as CNA F, had lowered the resident to the ground after the fall and notified the floor nurse, LPN B. In an interview with inspectors on September 26, LPN B confirmed she had been told about the incident and acknowledged she had not contacted the resident's family member immediately after it happened. She said the resident had already reached them himself before she could make the call.
That sequence, a nurse learning of a fall and not immediately notifying the emergency contact, while the injured resident handled his own family communication, ran directly against what facility leadership said should happen.
The Assistant Director of Nursing told inspectors that the nurse assigned to a resident, or the unit's own ADON, would normally be responsible for follow-up calls and family notification after any fall or incident. She said she would expect staff to document those contacts in the resident's medical record.
The Social Services Designee confirmed that the resident's family member was listed as his emergency contact. She also noted that the resident was listed as his own responsible person at the time of the incident. The charge nurse, she said, would be responsible for contacting the family or emergency contact whenever there was a change in condition or any incident involving the resident.
The Acting Director of Nursing, who also held a regional nursing role, told inspectors that the family member was contacted later that same day, and that the contact was noted in the fall investigation report. She said charge nurses are responsible for notifying emergency contacts in a timely manner after any new incident, fall, or change in condition.
What the facility's own social services notes from September 15 added was a detail that complicated the picture further. When staff documented the incident, they noted that the family member had been informed he or she was listed only as the resident's first emergency contact, and that the facility had no documentation showing that person held Durable Power of Attorney. The distinction mattered for what notifications were legally required and to whom.
Nobody disputed the basic facts: the resident fell, the resident fractured his knee, and the resident's family found out because he told them, not because a nurse called.
The fall itself, the mechanics of how it happened in the shower room, what equipment was in use, whether the shower aide followed proper procedure in lowering the resident to the ground, none of that was the focus of this particular citation. The inspectors were looking at what happened after, at who was responsible for making a phone call and whether anyone did.
LPN B did not call. The resident, injured, on the floor of a shower room, managed to reach his family before the facility's own communication chain produced a single outgoing call.
His family member drove him to the emergency room and learned there what Monterey Park's staff had not yet confirmed: that his knee was broken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monterey Park Rehabilitation & Health Care Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
MONTEREY PARK REHABILITATION & HEALTH CARE CENTER in INDEPENDENCE, MO was cited for violations during a health inspection on November 18, 2025.
He had just been lowered to the floor of a shower room at Monterey Park Rehabilitation & Health Care Center after a fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.