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 Independence Manor Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens, with incomplete water management paperwork, missing risk assessments, blank review sections, and no documentation that control measures or logbook activities were completed. Surveyors also observed a CMT using unclean scissors, failing to cleanse hands after medication administration, and not sanitizing a BP cuff, and observed a CNA assisting a cognitively impaired resident with meals while touching curtains, clothing, hair, and another resident’s plate without cleansing hands between tasks.
Improper Cleaning and Storage of CPAP/BiPAP Equipment and Distilled Water: A resident with sleep apnea and two residents with COPD/sleep apnea had CPAP masks observed sitting out or hanging without bags or dates, with visible soiling noted on one mask. Opened distilled water used for humidification was also found on the floor, undated, and in one case without a lid. Staff and the DON stated masks should be cleaned daily, air dried, and stored in dated bags, and opened distilled water should be dated and kept sanitary, but these practices were not being followed.
Failure to notify two residents with Medicaid coverage when their trust fund balances reached the SSI resource threshold and when they exceeded the limit. Both residents had account balances above the notification requirement, and both stated they were not told they were over the SSI limit; the BOM said no such notifications had been sent and was unaware of the requirement.
The facility failed to fully reflect resident needs in care plans. One resident with anxiety, bipolar disorder, schizophrenia, and severe cognitive impairment had a care plan that did not include goals or interventions for possessive and mildly aggressive behaviors involving baby dolls, despite staff observing repeated incidents. Another severely cognitively impaired resident had trazodone listed in the care plan for depression, while the physician order showed it was prescribed for insomnia.
Failure to provide reading access for a resident with severe vision impairment, stroke, depression, and dementia. The resident said he/she loved books but could no longer read after the stroke and had not been offered audio books or an e-reader. Records did not identify reading as an interest or include adaptive reading supports, and staff acknowledged that audio books from the public library or an e-reader were not obtained and the resident was not asked about them.
Failure to Provide Routine Dental Services: A resident with diabetes, osteoporosis, and severe cognitive impairment was observed with discolored teeth and several missing teeth, while staff and the family member were unsure whether the resident had ever seen a dentist. The care plan showed the resident was totally dependent on staff for oral care, but interviews revealed no record of dental visits and no dentist notes confirming the resident had been seen.
Food storage and temperature monitoring were not maintained as required. An opened gallon of milk, a pitcher of beverage, and an opened bag of tortilla shells were found without open dates, and an opened bag of marshmallows was not clearly dated. Refrigerator, freezer, and hot food logs also had missing entries for multiple shifts and meals, while the Head and Dietary Mgr stated temps were checked and recorded on logs.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program for the prevention of Legionella and other water-borne pathogens. Surveyors observed multiple water-related systems and areas throughout the building, including the municipal water main entry, sprinkler system, ice machine room, medication room sinks, housekeeping mop/service sinks, boilers, hot water storage tanks, recirculation pump, resident room bathrooms and sinks, laundry washers, and shower rooms. Review of the facility’s Legionella and Water Safety Program paperwork showed incomplete environmental assessment sections, blank pages, an errata page with uncompleted sections, no documented facility-specific risk assessment tied to ASHRAE standard 188, no assessment of individual area risk levels, no documentation that control measures had been performed, no site log book with dated cleanings or inspections, and blank educational review pages. A second version of the water management plan also lacked a signed and dated review page by the program team and contained numerous control measures without documentation that any tasks had been completed. During interview, the Maintenance Supervisor stated he/she was responsible for the water management plan, that water temperatures would be taken and samples sent to a lab for Legionella testing, and that the second section provided had not yet been put with the first paperwork. The Administrator stated the facility was supposed to have a committee responsible for the water management plan, but the Maintenance Supervisor oversaw it, that the second section had not initially been with the first because the Maintenance Supervisor had two separate binders and the plan was not updated, and that the assessments had been reviewed with the Maintenance Supervisor as best they could. The Administrator also stated he/she did not think the Maintenance Supervisor had ever really grasped what the program is, what it requires, and how it works. The facility also failed to follow its infection prevention policies during medication pass and meal service. During medication administration, a CMT used scissors to open a medication package and returned the scissors to the cart without cleaning them, did not cleanse hands after administering a medication patch to one resident, did not cleanse hands after administering medications and assisting another resident with water, milk, and pudding, and did not sanitize the blood pressure cuff after using it on a resident. During meal service, a CNA assisted a resident with lunch, left the table to close a curtain, then returned without cleansing hands, moved another resident’s plate and fed that resident with the same hand, and resumed feeding the original resident after adjusting pants and hair without cleansing hands. The resident being assisted with meals had dementia, a TIA, convulsions, muscle weakness, and severe cognitive impairment, and the care plan indicated the resident required assistance of one staff member to eat.
Improper Cleaning and Storage of CPAP/BiPAP Equipment and Distilled Water
Penalty
Summary
The facility failed to ensure CPAP/BiPAP masks were cleaned daily and failed to ensure distilled water used in respiratory equipment was stored in a sanitary manner for three residents. Facility policy required CPAP/BiPAP masks to be cleaned daily in warm, soapy water, rinsed, air dried, and stored in a clean bag, and required distilled water to be used in the humidifier chamber and kept in a sanitary manner. The Infection Prevention and Control Program also required reusable equipment such as masks to be cleaned daily and air dried between uses. One resident with obstructive sleep apnea had a CPAP mask observed on the nightstand on multiple occasions, not in a bag and not dated, with a light brown tinge around the perimeter of the mask. The resident stated the CPAP was used at night but did not know when staff last cleaned the equipment. The resident’s MDS did not show CPAP use, the physician order sheet did not include an order for CPAP or instructions for cleaning, and the care plan did not show CPAP use. A second resident with COPD and sleep apnea had a CPAP mask hanging over the headboard without a storage bag, and the humidifier compartment was half full. An opened gallon jug of distilled water was sitting on the floor without an opened date, and the resident stated staff used the water in the CPAP machine. A third resident with COPD and sleep apnea had a CPAP mask sitting on the nightstand without a bag or date, and the CPAP water reservoir was 3/4 full. The resident’s opened gallon jug of distilled water was also observed on the floor with no lid and no opened date. Staff interviews confirmed masks should be cleaned daily, air dried, and stored in a dated bag, and that opened distilled water should be dated, kept with a lid, and not left on the floor.
Failure to Notify Residents of Trust Fund Balance Limits
Penalty
Summary
The facility failed to notify two sampled residents who received Medicaid benefits when the balances in their resident trust accounts reached $200 less than the SSI resource limit for one person, and it also failed to notify them that they may lose eligibility for Medicaid or SSI if their accounts reached the SSI limit. The facility policy titled, Accounting and Records of Resident Funds, stated that a representative of the business office was responsible for informing residents when their personal funds account reached $200 less than the SSI limit and when the account reached the SSI resource limit for one person. Resident #14’s EHR showed Medicaid as the primary payer source. Quarterly trust statements for 2025 showed account balances of $8,496.62 on 3/31/25, $8,296.84 on 6/30/25, and $8,359.92 on 9/30/25, and the current balance on 12/8/25 was $8,285.31, which was $2,416.51 over the notification requirement limit. During interview, the resident said he/she did not know until that day that he/she was over the SSI limit. Resident #12’s EHR also showed Medicaid as the primary payer source. Quarterly trust statements for 2025 showed balances of $6,108.95 on 3/31/25, $6,069.02 on 6/30/25, and $6,141.99 on 9/30/25, and the current balance on 12/8/25 was $6,210.20, which was $341.40 over the notification requirement limit. During interview, the resident said no one told him/her he/she was over the SSI limit and that he/she did not know what it meant. The Business Office Manager stated that no notifications had been sent regarding residents reaching $200 less than the SSI resource limit and was not aware that notification was required.
Care Plans Missing Behavior Interventions and Medication Diagnosis Mismatch
Penalty
Summary
The facility failed to review and revise resident care plans to include resident behaviors for one resident and to have the correct diagnosis reflected for an ordered psychotropic medication for another resident. The report states that the comprehensive, person-centered care plan was to be prepared, reviewed, and revised by a team of health professionals, and that care plans were to include measurable objectives, identified problem areas, risk factors, treatment goals, timetables, and interventions targeted to the resident's needs. One resident had diagnoses including generalized anxiety disorder, bipolar disorder, and schizophrenia, and was severely cognitively impaired on the admission MDS. The resident's care plan identified impaired thought processes related to dementia and schizophrenia, but it did not include goals or interventions related to the resident's behaviors involving baby dolls. During observation, the resident showed mild aggression toward other residents on three occasions when they attempted to touch, take, or move the baby dolls, including snatching a doll away from another resident. Another resident had diagnoses including depression and insomnia and was also severely cognitively impaired on the quarterly MDS. The resident's care plan dated 10/17/25 stated the resident used antidepressant medication trazodone related to depression, while the physician order summary showed trazodone 100 mg, half tablet at bedtime, ordered for insomnia. Staff interviews indicated the resident was known to be possessive of baby dolls, had mood swings, hallucinations, and was easily redirected, but the care plan did not match the physician order for the trazodone indication.
Failure to Provide Reading Access for Visually Impaired Resident
Penalty
Summary
Provide activities to meet all resident's needs. The facility failed to provide the ability to listen to books for one sampled resident with severely impaired vision who loved to read. The resident had diagnoses including stroke, major depressive disorder, and dementia, and was described in records as dependent on staff for emotional, intellectual, physical, and social needs related to dementia and multiple comorbidities. The resident also had bilateral cataracts and impaired visual function, but the vision impairment care plan did not include adaptive equipment related to reading. The resident's assessments and activity records did not identify reading or books as an interest, and the activity assessment did not note any modification for the visual deficit. Documentation survey reports for October, November, and December 2025 showed audio books were not provided. During interview, the resident became tearful and stated that he/she had loved reading in a large home library, could no longer read after the stroke, missed reading, and had not been offered audio books or an electronic reader. The resident also said the facility had not asked about audio books or an electronic reader. Observation showed the resident sitting in the dining room not participating in an activity and not wearing glasses. The Activities staff member had not asked about audio books. The Activities Manager stated the resident was marked as not very interested in reading on the MDS because of poor vision, and the Administrator stated the resident should have been evaluated for activity interests, that a prior book club had ended when the staff member who read aloud quit, and that nothing had been done since then for the resident related to reading. The Administrator and Activities Manager both acknowledged that audio books from the public library or an electronic reader had not been obtained and that the resident had not been asked about them.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for one resident who was diagnosed with diabetes, age-related osteoporosis, and required assistance with personal care. The resident's admission MDS showed severe cognitive impairment, no natural teeth or tooth fragments, and no obvious cavity or broken natural teeth. The care plan stated the resident was totally dependent on staff for personal hygiene and oral care, and the physician order summary for December 2025 contained no orders for dental care. During observation, the resident was seen in the common area sitting in a wheelchair with discolored teeth and several missing teeth. The resident's family member said they were aware of missing teeth but had not been informed of any issues. Staff interviews showed uncertainty about whether the resident had ever seen a dentist: a CMT, CNA, and LPN all stated they were unsure if the resident had dental visits, while the LPN said aides attempted oral care but the resident was non-compliant and bit down on the toothbrush. The SSD said the dentist came to the facility and residents were placed on a list to be seen, but the resident had not been seen in a while, had been there a couple of years, and there were no notes from the dentist showing the resident had been seen. The Administrator also stated there was no record of the resident seeing the facility dentist and was unaware if the resident saw an outside dentist.
Food Storage and Temperature Logs Not Properly Maintained
Penalty
Summary
The facility failed to store food in a manner that prevented the potential of foodborne illnesses by not dating food wrappers and containers after they were opened, by failing to document refrigerator and freezer temperatures, and by not documenting prepared hot food temperatures prior to serving to residents. The facility census was 44 residents. The facility’s policy stated that food was to be stored, prepared, handled, and served to minimize the risk of foodborne illness, and that refrigeration was to be monitored at designated intervals throughout the day and documented. During observation, two opened items in the reach-in cooler were not labeled with an open date: a gallon container of whole milk and a pitcher of a beverage resembling apple juice. In dry storage, an opened 12-count bag of flour tortilla shells with eight shells remaining was not dated, and an opened bag of marshmallows dated 10/15 was stored next to seven unopened bags with the same date. Review of temperature logs showed missing documentation for the evening shift on 12/9/25 and the morning shift on 12/10/25 for the three-door fridge, two-door refrigerator, and freezer, and missing documentation for lunch on 12/9/25 and the morning meal on 12/10/25 for the hot food log. The Head [NAME] stated that food temperatures were checked for morning and noon meals, refrigerator and freezer temperatures were checked by staff on each shift, and the temperatures were documented on logs hanging on the unit doors. The Dietary Manager stated that refrigerator and freezer temperatures were monitored and recorded daily, that the person cooking was responsible for temping the food, and that opened food was expected to have a label showing the date the package was opened.
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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) |
|---|---|---|---|---|
| Rosewood Rehab And Healthcare Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Maywood Terrace Living Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Carmel Hills Wellness & Rehabilitation | 1.8 mi | ★★★★★ | 1 | 0 |
| Abode Health And Wellness Center | 3.3 mi | ★★★★★ | 6 | 0 |
| Rehabilitation Center Of Independence, The | 3.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.