Monarch Springs Rehab: Nurse Failed Follow-Up on Transfer - MO
Federal inspectors cited the facility following a complaint inspection completed December 31, 2025. The violation was tagged at the minimal harm level, meaning inspectors found no evidence the lapse caused serious injury, but the breakdown in basic communication protocol was clear.
LPN A was the nurse responsible. The report notes that LPN B, who was also present, was an orientee on his or her first day, which made LPN A's responsibility for the transfer more direct, not less. The standard steps were straightforward: call the physician, get an order, notify the guardian, document the change of condition. None of those last steps happened.
When inspectors sat down with the Director of Nursing and the Administrator on December 29, the DON confirmed LPN A had not completed proper follow-up. She said the guardian should have been called and the change of condition should have been recorded in the resident's chart. Then she said she did not know why it wasn't done.
The Administrator agreed with her.
What the family of that resident was told, and when, the inspection report does not say. What they knew in the hours after their loved one was transported to a hospital, and whether anyone at Monarch Springs reached out before inspectors arrived to ask questions, is not recorded anywhere in the facility's documentation, because there is no documentation.
That is the finding.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monarch Springs Wellness & Rehabilitation from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MONARCH SPRINGS WELLNESS & REHABILITATION in UNIVERSITY CITY, MO was cited for violations during a health inspection on December 31, 2025.
Federal inspectors cited the facility following a complaint inspection completed December 31, 2025.
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.