Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Rehabilitation Centers Of Independence West Campus during CMS and state inspections, most recent first.
The facility failed to respond promptly to resident call lights, resulting in multiple prolonged waits for assistance with transfers and basic needs. A resident with a compression fracture and diabetes waited over 20 minutes for help to use the restroom, while another with spinal stenosis and a vertebral disc replacement waited more than 30 minutes in a wheelchair to go to the bathroom. A resident with dementia and a hoarding disorder experienced repeated call light activations lasting up to nearly 40 minutes while needing help to retrieve a dropped bed controller and sit up in bed. Another resident with hypertension and weakness, dependent on a mechanical lift, reported that call light responses could take up to an hour. Despite a written policy requiring timely responses and an expectation communicated by the administrator, call light audits and observations showed significant delays.
A resident’s MDS was coded as if an anticoagulant had been used, but the EMAR and physician orders showed only antiplatelet medications (Aspirin and Ticagrelor), and the MDS Coordinator initially misclassified Ticagrelor. Another resident’s MDS failed to identify a PASRR Level II serious mental illness despite a PASRR outcome documenting bipolar disorder and major depressive disorder, with the record also showing anxiety, depression, bipolar disorder, and a history of psychotic symptoms and dementia.
A CNA failed to follow EBP for a resident with an indwelling catheter when emptying the catheter drainage bag. The CNA performed hand hygiene and donned gloves but did not wear a gown, despite EBP signage on the door and PPE available outside the room. The MDS Coordinator and IP both stated that gown and gloves were expected for catheter care, consistent with facility policy.
A cognitively impaired resident with a history of wandering and elopement risk exited the facility through an alarmed door after staff failed to properly investigate an activated alarm and account for all residents. The resident walked unaccompanied across the property and a street to a nearby hospital, where staff were only alerted to the absence after being contacted by hospital personnel. The resident was later found with minor abrasions but otherwise unharmed.
Surveyors found that the facility did not maintain a clean and homelike environment, with multiple areas—including hallways, resident rooms, and the dining room—having carpets with significant stains and discoloration. A resident expressed discomfort with the dirty dining room carpet, and both maintenance and housekeeping staff confirmed ongoing issues with cleanliness and ineffective cleaning efforts.
A resident with diabetes and foot ulcers did not receive a prescribed daily protein supplement for wound healing because staff failed to identify and implement the physician's order, as confirmed by the DON and an LPN.
The facility failed to respond promptly to resident call lights and did not ensure call lights were within reach for all residents. Two residents experienced repeated delays in staff response, with documented wait times often exceeding 20 minutes, and one resident was unable to access her call light when needed. These actions were inconsistent with the facility's policy for timely and accessible call light assistance.
A resident who was cognitively intact and required staff assistance for daily activities was solicited by a CNA to borrow money, which was sent electronically and only partially repaid. The CNA admitted to receiving the funds and not fully repaying the resident. Staff interviews confirmed the incident, and facility policy prohibits such actions, classifying them as exploitation.
A resident with multiple medical conditions, who was cognitively intact and required staff assistance, reported after discharge that a CNA borrowed money from him and only partially repaid it. The incident was not reported immediately by staff, and there was confusion about the reporting process and documentation. The facility did not notify authorities or initiate an investigation within the required timeframe, failing to follow its own abuse reporting policy.
A facility failed to provide a palatable and well-balanced diet, as evidenced by a resident's complaints about repetitive and unappetizing meals, including high salt content unsuitable for her high blood pressure. Additionally, during a meal service, three residents on a pureed diet received incorrect portion sizes, and food temperatures were not adequately monitored, resulting in cold food being served. The facility lacked policies on food palatability, temperatures, and portion sizes.
The facility failed to ensure proper use of PPE when handling soiled laundry. Staff A was observed wearing gloves but not a gown while placing soiled linens in the washing machine. The Environmental Supervisor was unaware of the requirement to wear a gown for all soiled linens, despite the facility's IPCP Guidelines indicating the need for appropriate PPE in the laundry area.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to provide timely responses to resident call lights, despite a policy requiring prompt response and a licensed nurse in charge on each shift. Surveyors used observation, resident and staff interviews, and computerized call light audits to determine that call lights were not answered in a timely manner for four of five reviewed residents, in a facility with a census of 56. One resident with no cognitive impairment and diagnoses including compression fracture, anxiety, and diabetes required staff assistance with transfers using a stand-up lift; this resident’s call light was observed on from approximately 7:37 a.m. to 8:00 a.m., and the audit showed activation at 7:35 a.m. for 24 minutes before staff entered, during which time the resident sat at the edge of the bed and stated he needed to use the restroom and that it often took a long time for staff to respond, especially in the morning. Another resident with no cognitive impairment and diagnoses including spinal stenosis and vertebral disc replacement, who required substantial to maximum assistance for transfers, had a call light on from approximately 12:02 p.m. to 12:30 p.m.; the audit showed activation at 11:59 a.m. for over 33 minutes, while the resident waited in a wheelchair and reported waiting a long time to go to the bathroom. A third resident with intact cognition and diagnoses including dementia and hoarding disorder, who required one staff for transfers, had a call light on from approximately 7:18 a.m. to 7:55 a.m.; the audit showed multiple activations lasting 16 to nearly 40 minutes, including one instance where the resident lay in bed waiting for staff to retrieve a dropped bed controller and assist her to sit up. A fourth resident with no cognitive impairment and diagnoses including hypertension and weakness, who required staff assistance and a mechanical lift for transfers, had a call light on from approximately 7:20 a.m. to 7:55 a.m., with the audit showing activation for nearly 32 minutes; this resident reported that it could take staff up to an hour to answer the call light. The administrator stated that the expectation was for staff to respond to call lights in a timely manner and to do the best they could, and the written policy stated that call lights shall be answered in a timely manner.
Inaccurate MDS Coding for Medication Use and PASRR Serious Mental Illness
Penalty
Summary
The facility failed to accurately code medication use on the MDS for one resident. Resident #1’s MDS showed a BIMS score of 7/15, indicating severe cognitive impairment, and documented use of anticoagulant and antiplatelet medications. However, the September and October 2025 EMARs showed the resident received Aspirin 81 mg daily and Ticagrelor 90 mg twice daily, both antiplatelet medications, and did not show any anticoagulant medication administration. A physician progress note also listed Aspirin and Ticagrelor orders for atrial fibrillation-related prophylaxis and stroke prevention, with no current anticoagulant order documented. During interview, the MDS Coordinator stated she initially thought Ticagrelor was an anticoagulant and later acknowledged both medications were antiplatelet agents. The facility also failed to accurately code PASRR information for one resident. Resident #18 had a 10/30/24 PASRR Level II outcome documenting serious mental illness related to bipolar disorder and major depressive disorder with significant symptoms affecting daily functioning, but the MDS A1500 did not identify a state Level II PASRR serious mental illness or related condition. The resident’s 11/20/25 MDS showed a BIMS score of 13/15, and the record listed anxiety, depression, and bipolar disorder. A 11/25/25 provider note documented follow-up for mental health and described a history of bipolar disorder with psychotic symptoms and dementia. The MDS Coordinator stated she generally relies on the physician diagnosis or PASRR and has access to the PASRR in the EHR.
Failure to Follow Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions for Resident #14, who had an indwelling catheter documented on the MDS assessment dated 9/9/25 and confirmed by the resident during interview on 12/8/25. An observation at that time showed an EBP poster on the resident’s door and a chest of drawers outside the room containing PPE. During an observation on 12/10/25 at 1:31 PM, Staff A, a CNA, entered the room to empty the catheter drainage bag, performed hand hygiene, and donned gloves, but did not don a gown as required by EBP. The MDS Coordinator acknowledged that staff should follow EBP and wear the required PPE, including a gown, and the Infection Preventionist stated staff are to follow EBP with catheters and would expect a gown and gloves when emptying a catheter. The facility policy on Infection Prevention and Control, last revised 7/31/24, directed staff to wear a gown and gloves during high contact resident activities and for residents with indwelling medical devices.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and ensure a safe environment for an ambulatory, cognitively impaired resident identified as an elopement risk. The resident, who had a history of dementia, severely impaired cognition (BIMS score of 0), daily wandering behaviors, and impaired safety awareness, was able to exit the facility through an alarmed door. The resident walked unaccompanied across the facility grounds, a residential street, and into a nearby hospital's ambulance garage. Staff were unaware of the resident's absence until notified by hospital personnel. The incident was precipitated by staff inaction following the activation of a door alarm. A dietary aide responded to the alarm, briefly looked outside in the dark, did not see anyone, and silenced the alarm without verifying the whereabouts of all residents. Other staff at the nurses' station did not further investigate the cause of the alarm or conduct an immediate headcount. The facility was experiencing alarm fatigue due to frequent non-emergency activations, particularly as the B-wing door was being used more often because of construction at the main entrance. This contributed to staff assuming the alarm was a false activation and failing to follow the facility's missing person policy, which required alarms to remain sounding until it was confirmed that no resident had left. The resident was later found by hospital staff, who contacted the facility. Upon return, the resident was assessed and found to have minor abrasions and redness on the palms, but was otherwise not in distress. The failure to properly respond to the door alarm and account for all residents resulted in the resident being unsupervised outside the facility, constituting a significant lapse in supervision and accident prevention.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment for its residents. Multiple areas throughout the building, including hallways, resident rooms, and the dining room, had carpets with significant dark stains, blackened discoloration, and ground-in dirt. The wallpaper border above the handrail in one hallway was partially removed and peeling in several areas. Staff interviews confirmed that the carpets had not been thoroughly cleaned since before Mother’s Day, with only spot cleaning performed, which was ineffective in addressing the persistent dirt and stains. The maintenance supervisor noted that recent heavy rainfall had caused water to enter the building, resulting in wrinkled carpets, and that a resident repeatedly peeled wallpaper from the walls, which had not been successfully repaired. A resident interviewed in the dining room expressed dissatisfaction with the dirty and worn carpet, stating it made her feel sick to eat meals in that environment. Staff members, including the maintenance and housekeeping supervisors, acknowledged ongoing concerns about the cleanliness and condition of the carpets, citing challenges such as humidity, rain, and the ineffectiveness of current cleaning efforts. These observations and interviews demonstrate the facility's failure to provide a safe, clean, and homelike environment as required.
Failure to Follow Physician Orders for Wound Care Supplement
Penalty
Summary
The facility failed to follow physician orders for one resident who had multiple diagnoses, including diabetes, heart failure, renal insufficiency, and diabetic foot ulcers. The resident's care plan identified a risk for skin integrity issues and directed staff to administer treatments as ordered by the physician. A wound clinic note included an order for a daily protein supplement (Prostat AWC) to assist with wound healing. However, staff missed this order, as it was not properly identified in the clinical documentation. Both the Director of Nursing and an LPN confirmed that the order was overlooked and not implemented as required by facility policy, which mandates correct transcription and administration of physician orders.
Delayed Call Light Responses and Inaccessible Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights and did not ensure call lights were within reach for all residents as required by policy. One resident with severe cognitive impairment and a history of falls was observed seated in a recliner with the call light placed on the bed, out of her reach, despite her care plan directing staff to keep the call light accessible. When the resident needed assistance to use the bathroom, she was unable to summon help until a staff member was alerted by the surveyor. The staff member acknowledged that the call light had not been placed on the resident's chair as it should have been. Additionally, two other residents reported and experienced significant delays in staff response to their call lights, with documented wait times frequently exceeding 20 minutes and sometimes reaching over 40 minutes. One resident, who was at risk for falls, stated that staff would sometimes turn off the call light and promise to return but failed to do so. Another resident, with a history of surgical repairs and chronic conditions, kept a log of delayed responses and reported incontinence episodes as a result of the delays. Review of computerized call light logs confirmed multiple instances of prolonged response times, contrary to the facility's policy requiring prompt and courteous responses to call lights.
Failure to Prevent Financial Exploitation of a Resident by Staff
Penalty
Summary
A deficiency occurred when a staff member, a CNA, solicited and received money from a resident who was cognitively intact and required staff assistance for daily activities. The resident reported that the CNA asked to borrow money, which was sent electronically via a cash application. The resident received only partial repayment and later discovered that the CNA had pretended to repay the remaining amount. The resident did not immediately report the incident, believing the CNA would repay the debt and not wanting to cause trouble, but later expressed concern about the potential for similar incidents with less alert residents. Interviews with staff confirmed that the CNA had borrowed money from the resident and had not fully repaid it. The DON and other staff acknowledged that borrowing money from residents is against facility policy and constitutes exploitation. The facility's policy prohibits staff from taking money or items from residents and requires reporting and investigation of suspected abuse or exploitation. The incident was identified through staff and resident interviews and review of transaction records.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident in a timely manner as required by policy and regulation. The incident involved a resident with multiple medical conditions, including anemia, atrial fibrillation, neurogenic bladder, paraplegia, and a pressure ulcer, who was cognitively intact and required staff assistance for daily activities. The resident reported after discharge that he had transferred $22 to a Certified Nursing Assistant (CNA) via PayPal, of which only $10 was repaid. This information was communicated to the facility after the resident had left. Staff interviews revealed that the incident was not reported immediately upon discovery. A Licensed Practical Nurse (LPN) learned of the situation while the resident was still in the facility but did not report it to the Director of Nursing (DON) until her next shift. The DON instructed the LPN to document the incident, and the statement was left for Human Resources. However, there was confusion and lack of clarity among staff regarding the exact dates and the process for reporting, and the written statement was not received by Human Resources. The Administrator and Human Resources both acknowledged the inappropriateness of the staff member borrowing money from a resident and confirmed that such incidents should be reported and investigated immediately. The facility's policy required immediate reporting of suspected abuse, mistreatment, or other criminal behavior to the person in charge and to the Administrator within one hour. Despite this, the allegation was not reported to the police or the Department of Inspections, Appeals and Licensing until several days after the resident's initial disclosure. The delay in reporting and lack of immediate action constituted a failure to follow established procedures for timely reporting and investigation of abuse allegations.
Deficiency in Dietary Services and Food Handling
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of its residents. Specifically, Resident #14, who is cognitively intact and has a history of diabetes, arthritis, and other conditions, reported dissatisfaction with the repetitive and unpalatable meals. The resident expressed concerns about the high salt content in meals, which is problematic given her high blood pressure. The care plan for Resident #14 included monitoring weight and providing a diet as ordered, but there was no documentation addressing the resident's complaints about the palatability of the food. Additionally, the facility lacked a policy for ensuring food palatability. During a meal service observation, the facility failed to maintain appropriate food temperatures and serve correct portion sizes for residents on a pureed diet. Three residents received a 4 oz portion of a pureed steak sandwich instead of the required 6 oz. The food temperatures were not checked before serving, resulting in cold food being served. The corporate dietician confirmed that the standard temperature for cold food should be 41 degrees Fahrenheit or colder, but the broccoli salad was served at 42.1 degrees Fahrenheit. The facility did not have policies related to food temperatures, palatability, or portion sizes, as confirmed by the administrator.
Inadequate Use of PPE in Laundry Handling
Penalty
Summary
The facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items, as observed during a survey. Staff A, responsible for laundry and housekeeping, was seen wearing gloves but not a gown while handling soiled tablecloths and cloth napkins, which were placed in the washing machine. After removing the gloves, Staff A closed the machine door and started the washer. During an interview, Staff A explained that gloves are worn for sorting regular laundry, while a gown, goggles, and gloves are used for isolation items, which are handled at the end of the day. The Environmental Supervisor stated that gloves are expected to be worn when sorting soiled laundry, but was unaware of the requirement to wear a gown for all soiled linens. The facility's Infection Prevention and Control Program (IPCP) Guidelines, revised in September 2022, indicate that handwashing facilities and appropriate PPE, including gloves and gowns, should be available for workers in the laundry area.
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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 Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buchanan County Health Center | 0.2 mi | ★★★★★ | 4 | 0 |
| Oelwein Health Care Center | 13.8 mi | ★★★★★ | 9 | 0 |
| Grandview Healthcare Center | 13.9 mi | ★★★★★ | 5 | 0 |
| Laporte City Specialty Care | 20.4 mi | ★★★★★ | 3 | 0 |
| Virginia Gay Nursing & Rehab, Llc | 21.8 mi | ★★★★★ | 0 | 0 |
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