Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Center Of Independence, The during CMS and state inspections, most recent first.
A resident with COPD, CHF, CKD stage 3, MDD, and anxiety, who was moderately cognitively impaired but able to communicate, discovered that money was missing from their bank account after receiving a lump-sum SSA back payment. While reviewing the account with a SW and a therapist, a $350 charge to a wireless carrier bearing the SSD’s name was identified, matching a prior text in which the SSD had asked the therapist to borrow $350 for a phone bill. The resident reported never authorizing the SSD to use their debit card, and bank records showed this payment along with multiple ATM withdrawals totaling several thousand dollars. The SSD denied using the resident’s card or receiving money, but the documented transaction, text messages, and interviews showed that the SSD used the resident’s funds to pay a personal cell phone bill, in violation of the facility’s abuse and misappropriation policy.
A resident with a history of falls and traumatic brain injury experienced a fall resulting in multiple injuries, including facial bruising, a laceration, and broken teeth. Staff notified the physician only about knee pain and did not report the facial injuries or broken teeth, nor did they fully document the extent of injuries or interventions provided. The physician and nurse practitioner were unaware of the full scope of injuries, and facility leadership confirmed that required notifications and documentation were not completed.
A facility failed to manage a diabetic resident's care, leading to hospitalization. The resident's insulin orders were not transcribed, and blood glucose monitoring was inadequate, resulting in hyperglycemia with a blood sugar level of 541 mg/dL. The resident exhibited signs of hyperglycemia, such as excessive hunger and anger, which were not recognized by staff. Interviews revealed a lack of awareness and inadequate processes for ensuring accurate transcription of physician's orders.
The facility failed to maintain adequate nursing staffing levels, as established by their own standards, resulting in a deficiency in providing appropriate care and services to residents. The facility's minimum staffing expectation was 2.8 nursing staff hours per patient per day (PPD), but this was not consistently met, with the lowest recorded at 2.03 PPD. The Administrator and DON acknowledged the routine failure to meet the staffing benchmark, potentially affecting all residents.
The facility failed to provide palatable foods at appropriate temperatures, affecting residents across multiple units. Residents reported meals being cold and served late, often due to staffing shortages. Despite ongoing complaints documented in Resident Council Meeting Minutes, issues persisted, with a test tray evaluation confirming improper food temperatures. The Food Service Supervisor and Administrator acknowledged the concerns.
The facility was unable to provide documentation of regular QAPI meetings and evidence of participation by required parties. The Administrator reported plans for monthly meetings but could not locate all attendance records since the last survey. Records were available for meetings in June, August, September, and October 2024, but no additional evidence of required meetings or attendance documentation was found, affecting all residents.
The facility failed to ensure dignified care for three residents. A resident with intact cognition was not provided with necessary adaptive feeding equipment, leading to frustration. Another resident was left without a bed, resulting in discomfort and inadequate rest. Additionally, a resident experienced a breach of dignity during perineal care when a staff member used profane language in their presence.
The facility failed to address ongoing grievances from residents regarding showers, laundry, and food shortages. Despite repeated reports in Resident Council meetings, issues such as missing laundry items, inadequate food supplies, and unclean rooms persisted. Interviews with the Administrator and DON indicated that while concerns were discussed in meetings, no actions were taken to resolve them.
The facility failed to provide adequate care for activities of daily living, including showers and toileting assistance, due to staffing shortages. Residents reported receiving fewer showers than scheduled, and one resident was left unattended on the toilet for over 20 minutes despite activating the call light. Staff interviews confirmed these issues, and there was no documentation of residents refusing care. The facility's policies on shower frequency and call light response were not followed, affecting the quality of care for multiple residents.
The facility did not employ a qualified social worker as required for facilities with more than 120 beds, impacting all 96 residents. The social worker held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervised experience. The social worker confirmed these deficiencies during an interview.
The facility failed to ensure proper infection control during wound care for two residents, as the LVN did not perform hand hygiene before donning gloves and touched surfaces before starting care. Additionally, Enhanced Barrier Precautions were not implemented for a resident with a pressure injury and catheter, as required by the care plan. Observations showed no signage or PPE available, and the DON acknowledged the oversight.
A resident's room was changed without prior notice while they were out for an appointment, leading to a misunderstanding with their former roommate. The facility's policy requires advance notice for room changes, but this was not followed, as confirmed by the social worker and acknowledged by the administrator.
A resident, who required a Hoyer lift for transfers, reported falling during a transfer by a Restorative Nursing Aide and Maintenance Supervisor. The staff did not notify the nurse or physician, and the incident was not documented in progress notes. The resident, with a history of brain injury and repeated falls, was later found with unreported abrasions on the left knee.
The facility did not provide appropriate notification of pending Medicare benefit changes for a resident. A review revealed that there was no documentation available for the required Beneficiary Notice for a resident discharged within the last six months. The Social Worker, new to the position, could not provide proof of notification letters sent to the resident.
A resident with a history of metabolic encephalopathy and CVA was transferred to a hospital due to a change in condition without the required written notice being sent to the resident or their representative. Facility staff, including an LPN and the DON, confirmed the oversight, which was against the facility's policy.
A resident was transferred to a hospital without receiving a written notice of the facility's bed-hold policy, as required by the facility's transfer and discharge policy. The resident, with a history of metabolic encephalopathy and hemiparesis, was transferred due to a change in medical condition. Interviews with staff confirmed the oversight, as the notice was not provided to the resident or their representative.
A facility failed to accurately document a resident's skin condition, compromising care. The resident, with a history of brain injury and falls, sustained abrasions during a transfer on admission day, which were not documented by the LVN. The resident reported falling, but staff stated the resident slipped without falling. The RNA involved was suspended and unavailable for comment.
A facility failed to timely obtain a physician-ordered urinalysis (UA) sample for a resident with multiple health conditions, including cellulitis and diabetes. The UA order was dated over a year before the sample was collected, with no explanation for the delay provided by the DON.
The facility failed to provide meaningful weekend activities for two residents and did not assist a resident in attending desired activities. A resident with intact cognitive status was not helped out of bed to attend bingo, while two other residents reported a lack of weekend activities, leading to boredom. Activity records confirmed limited participation in weekend activities, and the Activity Director acknowledged the absence of staff supervision on weekends.
The facility failed to supervise two residents while smoking, as required by its policy, leading them to smoke unsupervised in non-designated areas. Despite the policy mandating supervision and designated smoking areas, observations showed residents smoking near the front door without staff present. Interviews revealed that staff shortages and inaccessible designated areas contributed to this deficiency.
A resident with multiple diagnoses, including overactive bladder and chronic pain syndrome, did not receive proper perineal care as per facility policy. An RNA failed to adequately spread the resident's knees for cleaning, citing the resident's contracted state, while a CNA disagreed with the RNA's method. The resident, cognitively intact and dependent on staff for toileting, expressed dissatisfaction with the care, stating it was not done correctly.
A resident with dementia and a gastrostomy tube was not given prescribed supplemental feeding despite low meal intake. Observations and records showed the resident ate less than 50% of meals on several occasions, yet staff failed to administer Glucerna 1.5 as ordered. The DON confirmed that staff were expected to monitor intake and provide supplemental feeding as needed.
The facility did not follow the prescribed pureed diet menu for two residents, as observed during a meal service. The menu included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, the bread was not pureed and served to the residents, which was acknowledged by the Food Services Manager.
Misappropriation of Resident Funds by Social Services Director
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when the Social Services Director (SSD) used the resident’s debit card to pay the SSD’s personal cell phone bill in the amount of $350.00. The facility’s Abuse Prevention and Prohibition Program stated that each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property, and that the facility is committed to protecting residents from abuse by anyone, including staff. Despite this policy, the SSD’s name appeared on a $350.00 wireless cell phone carrier transaction drawn from the resident’s bank account, and the resident later reported missing money and denied authorizing the SSD to use the debit card for this purpose. The resident involved had multiple medical and psychosocial conditions, including COPD, chronic systolic (congestive) heart failure, chronic kidney disease stage 3, major depressive disorder (recurrent, moderate), and anxiety. A quarterly MDS showed the resident was moderately cognitively impaired but able to understand others and be understood. The resident’s care plan documented psychosocial well-being problems related to depression, anxiety, cognitive communication deficit, chronic pain, and respiratory insufficiency, and noted that the resident discovered missing money, which prompted an investigation and involvement of the police. Following discovery of the missing funds, the resident displayed increased tearfulness and reported never giving the SSD permission to use the debit card to pay a cell phone bill. Interviews and record reviews showed a sequence of events linking the SSD to the misappropriation. Therapist A reported receiving a text message from the SSD asking to borrow $350.00 to pay a cell phone bill; Therapist A declined. Later, while assisting the resident and Social Worker (SW) A in reviewing the resident’s bank account, Therapist A observed a $350.00 charge to a wireless carrier with the SSD’s name on it and took a picture of the transaction before reporting it to the Administrator. SW A stated that the resident came to the office upset that all of the resident’s money was gone, and that review of the account revealed the SSD’s cell phone bill payment. The resident had recently received a lump-sum Social Security back payment, paid the facility balance, and had about $9,000 remaining, with only about $1,000 left when the concern was raised. The Administrator reported that a total of $8,000 was missing from the resident’s account with multiple ATM withdrawals, that $350.00 was verified as taken by the SSD to pay a cell phone bill, and that law enforcement and the bank were investigating. Although the SSD denied using the resident’s debit card or receiving money or gifts from the resident, the bank record, the therapist’s text messages, and the resident’s statements collectively supported that the SSD used the resident’s funds without authorization, constituting misappropriation of property.
Failure to Notify Physician of All Resident Injuries After Fall
Penalty
Summary
The facility failed to ensure that a resident's physician was notified of all injuries sustained after a fall, as required by facility policy. The resident, who had a history of muscle weakness, repeated falls, and a traumatic subdural hemorrhage, experienced a fall resulting in multiple injuries, including a bruise to the right knee, facial bruising, swelling, a laceration to the top lip, and broken implanted teeth. While the fall was reported and an x-ray was ordered for the knee, there was no documentation that the physician was informed of the facial injuries or the broken teeth. The resident reported pain in the knee, hand, chin, and mouth, and described significant facial swelling and bruising, but these complaints and injuries were not fully communicated to the physician or addressed in the medical record. Interviews with staff revealed that the LPN who responded to the fall focused primarily on the resident's knee pain and did not recall informing the provider about the facial injuries or broken teeth. Other nursing staff assumed that all necessary notifications had been made and did not contact the physician regarding the additional injuries. Documentation in the progress notes and medical record was incomplete, with missing details about the location of pain, the extent of facial injuries, and the interventions provided, such as the application of steri-strips and ice packs. The physician and nurse practitioner both stated that they were not made aware of the full extent of the resident's injuries following the fall. Facility leadership, including the DON and Administrator, confirmed that their expectations were for all injuries and relevant facts to be reported to the physician and documented in the medical record. However, the investigation found that the required notifications and documentation did not occur, particularly regarding the resident's facial injuries and broken teeth. The lack of comprehensive assessment, notification, and documentation following the fall constituted a failure to follow facility policy and ensure appropriate medical oversight for the resident's injuries.
Failure to Manage Diabetic Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide appropriate care for a diabetic resident, leading to a significant health deficiency. Upon admission, the resident had a medical history of metabolic encephalopathy and diabetes, with specific orders for insulin administration and blood glucose monitoring. However, the facility staff did not transcribe or verify these orders, resulting in the omission of critical insulin doses and inadequate blood glucose monitoring. This oversight led to the resident experiencing hyperglycemia, with blood sugar levels reaching 541 mg/dL, and subsequent hospitalization. The resident exhibited signs of hyperglycemia, such as excessive hunger, anger, and frequent urination, which were not recognized or addressed by the facility staff. Despite the resident's disruptive behaviors and physical aggression, the staff did not assess or manage the resident's blood sugar levels appropriately. The facility's failure to implement the necessary care and services, as ordered by the medical provider, contributed to the resident's deteriorating condition and eventual transfer to a hospital. Interviews with the Administrator and the DON revealed a lack of awareness regarding the resident's unmonitored blood glucose levels and the unfulfilled insulin orders. The DON acknowledged the symptoms indicative of uncontrolled hyperglycemia but did not recognize them at the time of the resident's transfer. The facility's process for ensuring accurate transcription of physician's orders was inadequate, as evidenced by the missing checklist for the resident's admission. This deficiency highlights a critical lapse in the facility's care for diabetic residents, resulting in adverse outcomes for the resident involved.
Inadequate Nursing Staffing Levels
Penalty
Summary
The facility leadership failed to maintain adequate nursing staffing levels as established by their own standards, which resulted in a deficiency in providing appropriate nursing care and services to meet the needs of residents. The facility had set a minimum nurse staffing expectation of 2.8 nursing staff hours per patient per day (PPD), but a review of the facility's daily staffing hours for December 2024 revealed that this benchmark was not consistently met. On multiple days, the actual nursing staff hours worked were below the established minimum, with the lowest recorded at 2.03 PPD. During an interview with the Administrator and Director of Nursing (DON), it was acknowledged that the facility was routinely failing to meet the staffing benchmark. This deficiency had the potential to affect all residents living in the facility, as the inadequate staffing levels could compromise the quality of care and services provided to them. The report does not mention any specific residents or their conditions, focusing instead on the overall staffing inadequacies and the facility's failure to adhere to its own staffing standards.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to provide palatable foods per resident preferences for taste and temperature, as evidenced by improper food temperatures and delayed meal services. Multiple residents across four out of five units expressed concerns about the quality of food, specifically noting that meals were often cold and served later than the posted times. These issues were attributed to staffing shortages, which resulted in food trays sitting in hallways for extended periods before being served. Residents reported dissatisfaction with the taste and temperature of the food, with some opting to skip meals or order food from outside the facility. Resident interviews revealed consistent complaints about the food service, with residents describing meals as cold, unappetizing, and not served at the scheduled times. The Resident Council Meeting Minutes from the past five months documented ongoing issues with meal delays, lack of condiments, and unmet food preferences. Despite these documented complaints, the issues persisted, with residents continuing to express dissatisfaction with the food service during a recent Resident Council meeting. An observation of a breakfast meal service confirmed the residents' complaints, as a test tray evaluation showed that food temperatures were below acceptable levels. The Food Service Supervisor acknowledged that the food was too cold and had been left in the hallway for too long. The facility administrator also recognized the food complaints as a concern, indicating awareness of the deficiency but no immediate corrective actions were noted in the report.
Lack of Documentation for QAPI Meetings
Penalty
Summary
The facility was found deficient due to its inability to provide documentation of regular Quality Assurance Performance Improvement Plan (QAPI) meetings and evidence of participation by the required parties. During an interview, the Administrator stated that the committee planned to meet monthly but could not locate all verification of attendance for the QAPI meetings held since the last survey in June 2023. The Administrator provided records for meetings held in June, August, September, and October 2024, but there was no additional evidence of required meetings or documentation regarding those in attendance. This deficiency affected all facility residents.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for three residents, as observed during a survey. Resident #39, who had intact cognition and required setup or clean-up assistance for eating, was not provided with the necessary adaptive feeding equipment. Despite having an occupational therapy order for a built-up utensil, the resident was left without assistance, leading to frustration and a feeling of disrespect when staff were unavailable to help with meals. Resident #66, who had intact cognition and was typically independent with toileting, was found to be sleeping in a manual wheelchair due to the absence of a bed in the room. The resident reported difficulty with the provided rocking recliner and expressed a preference for a bed, which was not accommodated by the facility. The resident's care plan did not address the need for assistance with transferring from the recliner, leading to discomfort and inadequate rest. Resident #82, who was cognitively intact and dependent on staff for toileting hygiene, experienced a breach of dignity during perineal care. A Restorative Nursing Aide used profane language directed at another staff member in the resident's presence, compromising the resident's right to a respectful environment. This incident was reported to the facility's administration, highlighting a failure to maintain a dignified and respectful atmosphere during care interactions.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during multiple Resident Council meetings. Over several months, residents consistently reported issues such as not receiving showers, missing laundry items, and inadequate food supplies. Specific concerns included the dietary department running out of milk, yogurt, and condiments, as well as meal trays not matching dining tickets due to food shortages. Additionally, residents reported that their rooms were not being cleaned daily, and they were not receiving their clothing back from the laundry department in a timely manner. Despite these ongoing complaints, there was no evidence in the meeting minutes that facility leadership had addressed the residents' concerns. During an observation of a Resident Council meeting, residents continued to report issues with lost or damaged laundry, shortages of paper towels and hand soap, and rooms not being cleaned daily. Interviews with the Administrator and the DON revealed that while the concerns were discussed in leadership and Interdisciplinary Team meetings, no concrete responses or actions were provided to address the issues raised by the residents.
Deficiencies in ADL Care and Response to Call Lights
Penalty
Summary
The facility failed to provide necessary nursing care and services for activities of daily living to several residents, as observed in multiple instances. Resident #2, who has cerebral palsy and requires substantial assistance for showers and transfers, reported receiving fewer showers than scheduled due to staff shortages. The resident's care plan indicated a need for two showers per week, but records showed inconsistencies in meeting this requirement. Interviews with staff confirmed that short staffing often led to rescheduling or skipping showers, and there was no documentation of the resident refusing showers. Resident #58, with diagnoses including seizure and chronic obstructive pulmonary disease, also experienced a reduction in scheduled showers due to understaffing. Despite the care plan specifying two showers per week, the resident reported receiving only one per week and expressed frustration over the lack of assistance, particularly on weekends. The facility's policy required residents to sign a form if they refused showers, but there was no record of such refusals for Resident #58. Additionally, Resident #70, who is dependent on staff for toileting assistance, was left unattended on the toilet for over 20 minutes despite activating the call light. Observations showed multiple staff members, including maintenance employees and a COTA, ignoring the call light. The resident expressed frustration over the delay in assistance, which was confirmed by interviews with staff. The facility's policy emphasized timely responses to call lights, but this was not adhered to in Resident #70's case. Similar issues were noted for Residents #39 and #82, who did not receive adequate personal hygiene care and assistance with adaptive eating equipment as per their care plans.
Facility Lacks Qualified Social Worker for 120+ Bed Requirement
Penalty
Summary
The facility failed to employ a qualified social worker as required for facilities with more than 120 beds, affecting all 96 residents. The job description for the social worker position required a license in the state of practice, a bachelor's degree in social work or a related human services field, and one year of supervised social work experience in a healthcare setting with geriatric individuals. However, the social worker employed held a Bachelor of Arts in Human Services but was not licensed by the state and lacked the required year of supervision. During an interview, the social worker confirmed the absence of a license and the necessary supervised experience.
Infection Control Deficiencies in Wound Care and Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control during wound care for two residents. For Resident #82, the Licensed Vocational Nurse (LVN) did not perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage three pressure injury and intact cognition. Similarly, for Resident #26, the LVN also failed to perform hand hygiene before donning gloves and touched the curtain and bedside table before starting wound care. This resident had a stage four pressure injury and was moderately cognitively impaired. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Resident #37, who had a pressure injury and a suprapubic catheter. The care plan required EBP, including wearing a clean gown and gloves during high-contact activities. However, observations revealed no signage indicating EBP, and no personal protective equipment (PPE) was available inside or outside the resident's room. The Director of Nursing acknowledged the oversight and the need for proper signage and precautions.
Resident Room Change Without Notice
Penalty
Summary
The facility staff failed to protect the rights of a resident by changing their room without prior notice. The incident involved a resident who was admitted with multiple diagnoses, including diabetes, kidney failure, and anxiety disorder. The resident left the facility for an appointment and returned to find that their belongings had been moved to a different room without any prior notification. This unexpected change led to a misunderstanding between the resident and their former roommate, as each believed the other had requested the move. The facility's policy on room changes requires that residents and their representatives receive timely advance notice of any room changes, including written notice when the change is initiated by the facility. However, in this case, the social worker confirmed that the move was a clinical decision and acknowledged that the resident was not informed beforehand. The facility administrator stated that staff were expected to implement the policy correctly, indicating a failure in adhering to the established procedures for room changes.
Failure to Notify of Fall During Transfer
Penalty
Summary
The facility failed to ensure appropriate notification following a fall during a transfer for one of the residents. The resident, who was cognitively intact and required a mechanical Hoyer lift with two staff members for transfers, reported falling while being transferred from a wheelchair to the bed by a Restorative Nursing Aide and the Maintenance Supervisor. The staff involved did not notify the nurse or physician of the incident, as required, and there was no evidence in the progress notes that a fall had been reported. This oversight compromised the resident's right to prompt assessment and care. The resident had a history of diffuse traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls. During a skin assessment, the resident was found to have two closed abrasions below the left knee, which were not previously reported to the nurse. The Maintenance Supervisor admitted to assisting with the transfer and stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift. The incident was not properly documented or communicated, potentially placing the resident at risk for unrecognized or untreated injuries.
Failure to Provide Medicare Benefit Change Notification
Penalty
Summary
The facility failed to provide appropriate notification of pending benefit changes to Medicare services for one of the three residents sampled for beneficiary notices. During a review conducted on January 10, 2025, it was found that there was no documentation available for one resident regarding the Beneficiary Notice, which is required for residents discharged within the last six months. The Social Worker, who had been in the position since August 2024, was unable to provide proof of notification letters sent to the resident in question.
Failure to Notify Resident and Representative of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify a resident and the resident's representative of a facility-initiated emergency transfer to an acute care hospital. This deficiency affected one of the two residents reviewed for hospitalizations. The facility's policy required staff from Social Services or a designee to prepare a written transfer notice to accompany the resident during an emergency transfer. However, a review of the medical record for the affected resident revealed no evidence of such a notice being sent. The resident in question had a medical history that included metabolic encephalopathy, hemiparesis affecting the left side, and a history of cerebrovascular accident (CVA). The resident was transferred to the hospital due to a change in medical condition, but the required written notice of transfer was not completed or sent with the resident. Interviews with facility staff, including an LPN and the DON, confirmed that the notice was not sent, and the DON could not recall whether it was completed, despite having signed the resident's discharge summary.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and their representative upon the resident's transfer to an acute care hospital. This deficiency was identified during a review of the facility's policy on resident transfer and discharge, which mandates that such a notice be given at the time of transfer. The deficiency affected one of the two residents reviewed for hospitalizations, specifically a resident with a medical history of metabolic encephalopathy, hemiparesis, and a history of CVA. The resident was transferred to the hospital due to a change in medical condition, but no evidence of the required written notice was found in the resident's medical record. Interviews conducted with facility staff, including an LPN and the DON, confirmed that the notice of bed-hold policy was not provided to the resident or their representative. The LPN stated that the nurse responsible for the transfer should have completed and sent the notice with the resident as part of the transfer paperwork, and a copy should have been kept in the resident's medical record. The DON acknowledged the oversight, confirming that the notice was neither sent with the resident nor to the resident's representative.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a skin assessment for one resident, which compromised the ability to provide appropriate and timely care. The resident, who had a history of traumatic brain injury, cerebral infarction, morbid obesity, muscle weakness, and repeated falls, was admitted with an intact cognition score. The Admission Minimum Data Set (MDS) noted Moisture Associated Skin Damage (MASD) but no other skin problems. However, a Skin/Wound note created by an LVN on December 25th documented no skin issues, despite the resident having sustained an injury during a transfer on the day of admission. An observation on January 9th revealed two closed abrasions on the resident's left leg, which were not documented previously. The resident reported falling during a transfer on the admission day, resulting in a leg injury. The LVN was unaware of the injury or fall and had not documented the abrasions. The staff member involved in the transfer stated that the resident's admission paperwork did not indicate the need for a mechanical Hoyer lift, and the resident began to slip during the transfer but did not fall. The RNA involved was unavailable for an interview due to suspension.
Delayed Urinalysis Sample Collection
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) sample in a timely manner for a resident. The resident was admitted with multiple diagnoses, including cellulitis, heart disease, anemia, morbid obesity, infection of an unspecified joint, pain, and diabetes with diabetic neuropathy. A physician's order for a UA was dated 1/3/24, but the sample was not collected until 1/10/25. The Director of Nursing Services (DON) confirmed in an interview that the order was executed on 1/10/25, with no reason provided for the delay in obtaining the sample.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities on weekends for two residents and did not assist one resident in attending activities they wished to participate in. Resident #39, who has intact cognitive status and a preference for group activities, was not assisted by staff to get out of bed to attend activities such as bingo, which they expressed a desire to participate in. The resident also mentioned that they were not taken outside to smoke due to their inability to function independently. Resident #58, who has intact cognitive status and a preference for music, books, news, outside activities, and religious activities, reported a lack of activities on weekends. Despite being in the facility for two years, the resident stated that bingo was rarely offered on weekends, leading to boredom. Activity attendance records confirmed that the resident only attended two bingo activities on Saturdays over a three-month period. Resident #78, who also has intact cognitive status and a preference for group activities, religious activities, and music, expressed dissatisfaction with the lack of weekend activities. The resident noted that bingo was not consistently offered on weekends and expressed a desire for church services to be held at the facility on Sundays. The activity attendance records showed that the resident participated in only two weekend activities over three months. Interviews with the Activity Director revealed that weekend activities were not staffed, and only bingo was supervised every other Saturday.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not adhering to its smoking policy, which mandates that residents smoke only in designated areas under staff supervision. Two residents, both with unimpaired cognition, were observed smoking near the facility's front door without supervision. The facility's policy, revised in November 2023, clearly states that smoking is only permitted in designated areas and must be supervised by staff. However, observations on multiple occasions revealed that these residents were smoking unsupervised in non-designated areas. Resident #13, with a medical history of chronic obstructive pulmonary disease and hemiparesis, was observed smoking unsupervised near the facility's front door on several occasions. Despite being aware of the facility's smoking procedures, Resident #13 reported that staff were not adhering to the established smoking times, leading the resident to smoke independently. Similarly, Resident #20, who also has hemiparesis and uses tobacco, was observed smoking unsupervised with Resident #13. The resident reported that the designated smoking area was inaccessible due to snow, forcing them to smoke in non-designated areas. Interviews with facility staff, including an LPN and the Administrator, confirmed that the designated smoking area was the rear patio and that all residents required supervision while smoking. However, the LPN acknowledged the difficulty in monitoring residents due to limited staff availability. The Administrator confirmed the facility's smoking policy but did not provide a clear explanation of how compliance with the policy was ensured. This lack of supervision and adherence to the smoking policy constitutes a deficiency in maintaining a safe environment for residents.
Inadequate Perineal Care Provided to Resident
Penalty
Summary
The facility failed to provide appropriate perineal care to prevent urinary tract infections for one resident. The facility's policy on perineal care, revised in June 2020, outlines specific procedures for cleaning female residents, including washing, rinsing, and drying from front to back using a clean washcloth for each stroke. However, during an observation, a Restorative Nursing Aide (RNA) did not spread the resident's knees apart adequately, which hindered proper cleaning. The RNA claimed that the resident's contracted state prevented proper leg positioning, but a Certified Nurse Aide (CNA) present disagreed, stating that the RNA did not clean the resident properly and could have done better. The resident involved, who was admitted with diagnoses including ventricular tachycardia, overactive bladder, major depressive disorder, and chronic pain syndrome, was cognitively intact and dependent on staff for toileting hygiene. The resident was frequently incontinent for bladder and always incontinent for bowel. The resident's care plan noted behavior issues related to incontinence care, with the resident expressing dissatisfaction with the way staff performed perineal care. In an interview, the resident confirmed dissatisfaction with the care provided, stating that the RNA did not change or wipe them properly and incorrectly applied the brief.
Failure to Administer Prescribed Supplemental Feeding
Penalty
Summary
Facility staff failed to ensure that a resident with a feeding tube received the appropriate treatment and services to maintain nutritional status. The resident, who has a medical history of dementia and a gastrostomy tube, was observed eating only 25% of a lunch meal, yet the staff did not administer the prescribed supplemental tube feeding as per the physician's orders. The orders specified that if the resident consumed less than 50% of meals, Glucerna 1.5 should be administered via the feeding tube, which was not done. Further review of the resident's records showed a pattern of inadequate meal intake without the corresponding administration of the prescribed supplemental feeding. The resident's care flow records indicated low meal consumption on multiple occasions, yet there was no documentation of the PRN Glucerna being administered. An interview with the Director of Nursing revealed that the nursing staff were expected to monitor meal intake and administer the supplemental feeding as needed, which was not adhered to in this case.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed pureed diet menu for two residents, as observed during a meal service. According to the facility's policy on Therapeutic Diets, each food item in a regular diet should be pureed and served separately for residents on pureed diets. On the specified date, the noon menu for residents with pureed diets included pureed BBQ meatballs, mashed potatoes with gravy, pureed buttered peas, pureed brownie, and pureed buttered white bread. However, during the preparation and serving of the meal, the bread was not pureed and served to the residents as required. The Food Services Manager acknowledged that the menu was not followed, resulting in the deficiency.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 819 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Independence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Abode Health And Wellness Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Carmel Hills Wellness & Rehabilitation | 1.8 mi | ★★★★★ | 1 | 0 |
| Sunterra Springs Independence | 2.5 mi | ★★★★★ | 0 | 0 |
| Jackson Creek Post Acute | 2.9 mi | ★★★★★ | 21 | 0 |
| Independence Manor Care Center | 3.6 mi | ★★★★★ | 17 | 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.