Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Independence Health And Rehabilitation during CMS and state inspections, most recent first.
Unreadable Dishwasher Gauge and Missing Temperature Logs: The facility failed to maintain dishwasher temperature monitoring when the gauge was hazed and unreadable and no temperature log was available. The RD acknowledged the unreadable gauge, the Maintenance Supervisor said it needed replacement, and the Administrator stated there was no temperature record log even though the dishwasher temperature was supposed to be checked daily. A probe later showed the dishwasher water at 134 degrees F.
Improper Storage of Opened Food Items: A kitchen tour found several opened food items stored without labels or dates, including cereal, ranch dressing, boiled eggs, and cheese. A Cook confirmed the items were undated, and an RD later stated food products were to be dated immediately when opened.
Staff failed to follow infection control practices involving catheter positioning, hand hygiene, and EBP. A resident’s catheter was repeatedly observed resting on the floor, a CNA provided high-contact care to a resident with an indwelling catheter without donning a gown, an LPN handled medication-cart items without hand hygiene after dropping an item on the floor, and a resident with a PICC line received IV/PICC care without the expected PPE.
Failure to Provide Flu and Pneumococcal Vaccines: The facility did not provide influenza and pneumococcal vaccines for 3 sampled residents. One resident with MS had no documentation of being offered or receiving a flu shot, another resident with osteomyelitis had an incomplete multi-vaccine consent form and did not receive an updated pneumococcal vaccine despite prior PCV 13 history, and a third resident with kidney failure consented to influenza immunization but did not receive it.
Failure to offer and document COVID-19 vaccination for 3 sampled residents was identified during record review. A resident with MS had no evidence of being offered or receiving the vaccine, a resident with osteomyelitis signed a multi-vaccine consent form but did not accept or decline the COVID-19 vaccine, and a resident with kidney failure consented to receive the vaccine but did not receive it. The ADON/LPN Resident Care Manager confirmed the missing documentation and lack of vaccination.
Failure to inform two residents of the risks and benefits of psychotropic meds. One resident with depression was ordered citalopram, and another resident with esophageal obstruction was ordered clonazepam for anxiety, but the record showed no indication either resident was informed in advance of the risks and benefits. The DNS confirmed both omissions.
Mold was observed in the east hall linen closet, where multiple black spots were seen in the lower left corner and blankets were touching the affected wall area. A CNA reported a mold odor at times and confirmed the area appeared to have mold, and the Maintenance Supervisor later verified the mold in the closet.
A resident with osteomyelitis was admitted to hospice, but the facility did not complete the Significant Change MDS within the required 14-day timeframe. The MDS Coordinator later confirmed the assessment was completed 17 days after hospice admission.
Failure to provide personal care for a resident who needed help with ADLs. A cognitively intact resident with schizophrenia and major depressive disorder had long, thick facial hair and stated a preference for short facial hair, but CNAs did not offer shaving or trimming since admission. Staff said shaving was typically offered on scheduled bathing days, and an LPN was unaware of the resident's grooming preferences.
A resident with chronic idiopathic constipation did not receive ordered PRN bowel medication despite going four days without a BM. The physician orders included PRN sennosides, PEG 3350, and Milk of Magnesia after three days without a BM, but the bowel record and MAR showed no PRN constipation meds were given or refused. An ADON/LPN confirmed nursing staff were expected to offer and administer one of the ordered PRN bowel meds.
Failure to complete ordered wound care was identified for a resident with leg amputation and pressure ulcers to the back. Staff documented that daily dressing changes were not completed and were passed to the next shift, but the care still was not done. A complaint also stated the resident had multiple unstageable pressure ulcers, wound care was not always provided, the wounds worsened, and the resident was sent to the hospital.
A resident with esophageal obstruction was ordered NPO and on tube feeding, but a CNA served orange juice during fluid pass before breakfast. The resident consumed a small amount before it was removed, and staff documented that the physician orders and care plan were not followed.
Improper Catheter Bag Placement: A cognitively intact resident with an indwelling urinary catheter had the drainage bag repeatedly observed on the wheelchair seat above the bladder, between the leg and armrest. CNAs and an LPN acknowledged the bag was not in the proper position, and staff stated the resident often placed it there and needed reminders or assistance to keep it below the bladder.
Incomplete Direct Care Staff Daily Reports were posted at the facility entrance because the evening shift section was left blank on multiple occasions. An LPN stated the charge nurse was responsible for completing and posting the report at the start of each shift and confirmed the evening shift section was not completed, and the DNS acknowledged the postings were not completed as required.
Two residents experienced falls due to staff not following care plans requiring two-person assistance for transfers. One resident, with dementia and hemiplegia, fell and fractured their femoral neck when a CNA attempted to assist alone. Another resident, post-stroke and at risk for falls, was transferred by a CNA without reviewing the care plan, resulting in a fall without injury. Both incidents highlight a failure to adhere to care plans, risking resident safety.
The facility failed to maintain a homelike environment, with issues such as exposed drywall, loud bathroom fans, and a cold shower room affecting residents. A resident's room had unpainted drywall due to water damage, while others experienced loud fan noises. The shower room was cold due to an incorrectly installed fan. Staff acknowledged these issues, but they remained unresolved, impacting residents' comfort.
A facility failed to obtain and implement PASARR findings for a resident with mental health issues and visual impairment. Despite a PASRR Level II evaluation recommending increased medication and psychiatric referral, the facility did not receive a revised evaluation and failed to follow up, resulting in the resident not receiving necessary mental health resources.
A resident with a stroke diagnosis did not receive a restorative program as recommended by OT to maintain and improve ROM. Despite a referral for exercises and a hand splint, staff did not implement the program, leading to decreased ROM. Interviews and observations confirmed the lack of intervention.
A resident with heart disease was prescribed multiple blood-thinning medications, and pharmacy recommendations to evaluate and potentially discontinue some were not acted upon timely by the physician. Additionally, recommendations for a gradual dose reduction of sertraline were not addressed, with staff acknowledging delays in physician response.
A resident with a cerebral hemorrhage experienced consistent loose stools and expressed concerns about bowel incontinence. Despite reporting these issues to CNAs, the resident's bowel movements remained mostly soft or loose over 30 days. The resident was on a laxative medication, Senna-Docusate Sodium, for constipation. The DNS expected CNAs to report concerns to the charge nurse, who should then inform the practitioner to adjust medications during weekly visits.
Two residents were found without working call systems in their bathrooms, posing a risk for inability to call for assistance. One resident with heart failure and cognitive impairment, and another with diabetes, both required assistance for bathroom transfers. The Maintenance Director confirmed the absence of call light cords, and the issue was not reported in the maintenance log. The Administrator was aware but did not replace the cords until two days later.
A resident with a leg wound experienced worsening conditions due to the facility's failure to provide adequate care. The wound, initially managed with a vacuum, was not consistently assessed or documented as per the facility's policy. A physician's order for wound care was not entered into the TAR, and there was a lack of documentation for care on specific dates. The resident's wound became necrotic and infected, leading to sepsis and the need for debridement. Staff interviews revealed inconsistencies in wound care practices and a lack of treatment supplies.
A resident with chronic pain conditions experienced inadequate pain management due to delays in receiving PRN medications and lack of necessary wound care supplies. Despite frequent complaints, the facility staff failed to address the issue, leading to increased pain levels and affected daily activities.
Unreadable Dishwasher Gauge and Missing Temperature Logs
Penalty
Summary
The facility failed to maintain essential kitchen equipment by not keeping the dishwasher temperature gauge readable and not maintaining temperature monitoring records for the dishwasher. During observation, the dishwasher gauge was hazed and unreadable, and the Registered Dietician acknowledged it was unreadable while the Dietary Manager was on vacation. Review of the May 2026 dishwasher log showed no temperature monitoring. The Maintenance Supervisor acknowledged the gauge needed replacement and stated the dishwasher temperature was tested with a thermometer on a regular basis, but no temperature record could be provided. A temperature probe later showed the dishwasher water at 134 degrees Fahrenheit, while the Dietary Aide stated she monitored chemical levels but did not monitor dishwasher temperature. The Administrator stated the facility did not have a temperature record log for the dishwasher and that the temperature was to be checked daily.
Improper Storage of Opened Food Items
Penalty
Summary
Food was not stored in a sanitary manner in the kitchen during a brief tour, as several opened food items were found without required labels or dates. An opened bag of cereal in dry storage was unlabeled and undated, an opened container of ranch dressing in the refrigerator was undated, an open bag containing eight boiled eggs in the refrigerator was unlabeled and undated, and an open block of cheese in the refrigerator was loosely wrapped and undated. A Cook stated staff were to date food products when opened and add a use-by date, and confirmed the open items were undated. A Registered Dietician later stated staff were to date any food product immediately when opened and discard any items found without dates.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to implement infection prevention and control measures related to catheter positioning, hand hygiene, and Enhanced Barrier Precautions for residents with indwelling medical devices. Resident 4’s catheter was observed attached to the bed with part of the catheter resting on the floor on multiple observations, and staff members confirmed the catheter was on the floor before a basin was placed under it. The Infection Preventionist later stated resident catheter bags were not to rest on the floor. Resident 8 had an indwelling catheter and was observed receiving assistance into the bathroom by a CNA who wore gloves but did not don a gown while providing care. The CNA stated he escorted the resident to the bathroom and emptied the catheter bag, and nursing leadership stated staff were expected to follow Enhanced Barrier Precautions for high-contact care involving the catheter or catheter bag. Resident 29 had a PICC line, and staff and the resident stated PPE was not worn when IV medications or PICC care were provided; an LPN was observed disconnecting IV medication and beginning a flush protocol without donning a gown, and later stated a gown was not needed because the resident did not have open wounds. In addition, an LPN was observed at the medication cart drop a cotton ball on the floor, discard it, and place the lid on an insulin pen without completing hand hygiene.
Failure to Provide Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide influenza and pneumococcal vaccines for 3 of 5 sampled residents reviewed for immunizations. Resident 4, who was admitted in 2024 with multiple sclerosis, had no documentation showing an influenza vaccine was offered or received in 2025. On 5/8/26, Staff 3, the Assistant Director of Nurses/LPN Resident Care Manager, reviewed the record and confirmed there was no evidence Resident 4 was offered or received an influenza vaccine. Resident 6, admitted in 2025 with osteomyelitis, had documentation of a PCV 13 vaccine in 2017, but the record review showed another pneumococcal vaccine was needed to be current per CDC recommendations. The resident had a 11/4/25 Multi-Vaccine Consent Form signed, but it was incomplete and did not show pneumococcal vaccines were accepted or declined. Staff 3 confirmed on 5/8/26 that Resident 6 did not receive an updated pneumococcal vaccine and that the consent form was not completed thoroughly. Resident 14, admitted in 2025 with kidney failure, had no documentation of an influenza immunization in 2025, and although a 12/18/25 Multi-Vaccine Consent Form showed consent for influenza immunization, Staff 3 confirmed on 5/8/26 that the resident did not receive the influenza immunization.
Failure to Offer and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer a COVID-19 vaccine for 3 of 5 sampled residents reviewed for immunizations. Resident 4, who was admitted in 2024 with multiple sclerosis, had no documentation in the immunization record showing that a COVID-19 vaccine was offered or received in 2025. On 5/8/26, the Assistant Director of Nurses/LPN Resident Care Manager reviewed the record and confirmed there was no evidence Resident 4 was offered or received the vaccine. Resident 6, admitted in 2025 with osteomyelitis, had no documentation of a COVID-19 vaccine in 2025. The medical record included an 11/4/25 Multi-Vaccine Consent Form signed by the resident, but the COVID-19 vaccine was neither accepted nor declined. The Assistant Director of Nurses/LPN Resident Care Manager confirmed on 5/8/26 that Resident 6 did not receive an updated COVID-19 vaccine and that the consent form was not completed. Resident 14, admitted in 2025 with kidney failure, also had no documentation of a COVID-19 immunization in 2025. A 12/18/25 Multi-Vaccine Consent Form signed by Resident 14 showed consent to receive a COVID-19 immunization, but the Assistant Director of Nurses/LPN Resident Care Manager confirmed on 5/8/26 that the resident did not receive the immunization.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents were informed in advance of the risks and benefits of psychotropic medications for 2 of 5 sampled residents reviewed for unnecessary medications. Resident 4, who was admitted in 2024 with a diagnosis including depression, had a physician order for citalopram on 1/6/26, but the medical record showed no indication that the resident was informed in advance of the risks and benefits of citalopram. On 5/11/26 at 1:19 PM, the DNS confirmed Resident 4 was not informed of the risks and benefits of citalopram. Resident 43, who was admitted in 5/2026 with diagnoses including esophageal obstruction, had a 5/2/26 physician order for clonazepam for anxiety, but the medical record showed no indication that the resident was informed in advance of the risks and benefits of clonazepam. On 5/8/26 at 11:35 AM, the DNS acknowledged Resident 43 was not informed of the risks and benefits for the use of clonazepam.
Mold in East Hall Linen Closet
Penalty
Summary
The facility failed to ensure residents had unsoiled, clean linens in 1 of 3 linen closets reviewed. On observation, the east hall linen closet had multiple black spots in the left lower corner of the wall, and multiple blankets were touching the black spots. A CNA stated there was a mold odor in the east linen closet at times and confirmed the area appeared to have mold in the lower left corner. The CNA removed the blankets and sent them to laundry. The Maintenance Supervisor stated he was unaware of any concerns with mold in the east linen closet and then looked in the closet and confirmed there was mold in the lower left corner.
Delayed Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change MDS within the required timeframe for one resident reviewed for hospice services. Resident 6 was admitted to the facility in 11/2025 with diagnoses including osteomyelitis, and a progress note dated 4/21/26 documented admission to hospice services on that date. A Significant Change MDS was completed on 5/7/26, which was 17 days after the resident was admitted to hospice. On 5/8/26 at 10:55 AM, the MDS Coordinator reviewed the assessment and confirmed it was not completed within 14 days after the resident was admitted to hospice.
Failure to Provide Requested Facial Grooming
Penalty
Summary
Provide care and assistance with activities of daily living was not fully provided for one resident who needed help with personal care, including shaving. The resident was admitted with diagnoses including schizophrenia and major depressive disorder. The admission MDS dated 4/22/26 indicated a BIMS score of 14, showing the resident was cognitively intact, and that staff assistance with personal care, including shaving, was required. On 5/4/26, the resident was observed in the room with long, thick facial hair and stated a preference for short facial hair, but staff had not offered to trim or shave it since admission. Multiple CNAs stated they had provided care to the resident but did not offer shaving or trimming of facial hair, and one CNA said this was only done on scheduled bathing days. An LPN stated the resident was timid and reluctant to communicate needs and was unaware of the resident's facial hair or personal care preferences. The ADON/LPN Resident Care Manager stated staff were expected to offer shaving or trimming as needed based on resident preference or scheduled bathing days and confirmed the resident had been in the facility long enough for those preferences to be known and accommodated.
Failure to Provide Ordered PRN Constipation Medication
Penalty
Summary
The facility failed to provide PRN bowel medication according to orders for Resident 34, who was admitted with chronic idiopathic constipation. The resident’s physician orders dated 4/17/26 included sennoside 8.6 mg and polyethylene glycol 3350 powder PRN for constipation, and also ordered Milk of Magnesia PRN after three days without a bowel movement. The bowel record showed no bowel movement from 4/21/26 through 4/24/26, a four-day period, and the 4/2026 MAR showed no indication that any PRN constipation medication was given or refused during that time. Staff later confirmed that the resident went four days without a bowel movement and did not receive PRN constipation medications, and that nursing staff were expected to offer and administer one of the ordered PRN constipation medications on 4/24/26.
Failure to Complete Ordered Wound Care
Penalty
Summary
Failure to implement ordered wound care was identified for one resident with diagnoses including leg amputation and pressure ulcers. A 3/27/26 physician order directed staff to perform wound care to the pressure ulcers on the resident’s back every day shift. Progress notes on 4/6/26 and 4/10/26 documented that wound care was not completed and that staff passed the treatment on to the next shift. The complaint received on 4/22/26 stated the resident was admitted with multiple unstageable pressure ulcers to the back, that staff did not always provide wound care, that the wounds worsened, and that the resident was sent to the hospital. Staff interviews on 5/7/26 and 5/11/26 confirmed the resident had a bariatric bed and mattress, preferred to stay on the back and did not get out of bed as often as he/she should have, and that the ordered daily dressing changes to the back were not completed on 4/6/26 and 4/10/26, with the task intended to be passed to the next shift but not completed then either.
NPO Resident Given Juice Despite Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were followed to prevent accidental choking for one resident who was admitted with diagnoses including esophageal obstruction and had a care plan for enteral nutrition with orders to remain NPO. The resident's care plan dated 5/1/26 indicated tube feeding was required related to the esophageal obstruction, and the physician's orders also stated the resident was NPO. On 5/7/26, a family member stated the resident was served juice at breakfast and was coughing. A staff member later stated the resident had been served juice by a CNA and consumed approximately half of a sip before it was removed, and the resident was evaluated and the incident reported to the administrator. The progress note documented that the resident consumed five milliliters of juice orally, and the incident report stated the resident was provided juice by a CNA who wrote that she did not see the tube feed and gave juice until told the resident could not have it. The DNS stated the CNA served orange juice while passing fluids before breakfast service and that the physician orders and care plan were not followed.
Improper Catheter Bag Placement
Penalty
Summary
The facility failed to ensure proper catheter bag placement for one resident with an indwelling urinary catheter. The resident was admitted in 2/2025 with diagnoses including pneumonia, and the 2/6/26 Annual MDS indicated the resident was cognitively intact and had an indwelling urinary catheter. The care plan, revised on 12/17/25, identified the catheter and included interventions to change from a leg bag to a drain bag for day and night use and to encourage proper positioning of the catheter and drainage bag. Multiple observations from 5/4/26 through 5/6/26 showed the resident sitting in a wheelchair with the catheter drainage bag placed on the wheelchair seat, above the bladder, between the resident's leg and the armrest. A CNA stated the resident frequently placed the bag above the bladder and staff were expected to remind the resident to reposition it below the bladder. Another CNA was observed assisting the resident while the bag remained in that same position and stated he did not remind the resident to move it below the bladder. An LPN stated the bag was not in the proper position and needed to remain below the bladder, and the DNS stated the bag was to remain below the bladder at all times and staff were expected to assist the resident with maintaining proper placement.
Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to post complete Direct Care Staff Daily Reports at the entrance because the evening shift section was left blank on multiple dates. Observations on 5/4/26, 5/5/26, and 5/6/26 showed the evening shift portion of the staffing report was not completed and posted. On 5/6/26, an LPN stated the charge nurse was responsible for completing and posting the report at the start of each shift and confirmed she did not complete the evening shift section. The DNS later stated she was aware of prior incidents when the evening shift section was not completed and posted timely, and acknowledged it was not completed as required from 5/4/26 to 5/6/26.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that two residents were transferred according to their care plans, leading to falls and potential injury. Resident 2, who was non-verbal and diagnosed with dementia and hemiplegia following a stroke, required the assistance of two caregivers for personal care. However, a former agency CNA did not review the care plan and attempted to assist the resident alone, resulting in a fall and a fracture of the right femoral neck. The CNA admitted to not being aware of the care plan requirements, and the LPN on duty confirmed that assistance was readily available if requested. Similarly, Resident 31, who had a history of stroke and was at risk for falls, required two-person assistance for transfers. Despite this, an agency CNA attempted to transfer the resident alone after the resident insisted they only needed one person. The CNA did not review the care plan before the transfer, leading to the resident becoming weak and being eased to the floor, though no injury occurred. The DNS verified that the resident was not transferred as care planned, resulting in a fall.
Facility Fails to Maintain Homelike Environment Due to Disrepair and Noise
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several instances of disrepair and noise disturbances. Resident 35's room had an unpainted area with exposed drywall behind the headboard, which had been in disrepair for a while. Staff 17, a CNA, acknowledged the issue, and the Maintenance Director, Staff 12, confirmed that the wall had been down for two months due to ongoing water damage. Similarly, Resident 31's bathroom had a cut, unpatched, and unpainted drywall area behind the toilet, which Staff 12 admitted had not been repaired despite frequent leaks. Several residents, including Residents 20, 38, and 19, experienced loud, metal rattling noises from bathroom fans when activated. Resident 20, who was cognitively impaired, stated the fan had been loud for years, and Staff 12 verified the noise. Resident 38, with moderate cognitive impairment, also reported the fan noise, and the drywall behind the toilet was similarly cut and unpatched. Staff 1, the Administrator, was not notified by residents or staff about the noisy fans, contributing to an unhomelike environment. Additionally, the [NAME] Hall shower room was consistently cold, with cold air being pushed down from the ceiling when the fan was activated. Staff 14, a CNA, reported the issue to Staff 12, who later identified that the fan was installed incorrectly. Resident 11, who was cognitively intact, confirmed the cold air issue and stated they had to be transported to another hall for showers. Staff 1 acknowledged the need for prompt drywall repairs to ensure a quality living environment, but these issues remained unresolved, leading to an uncomfortable and unhomelike environment for the residents.
Failure to Implement PASARR Recommendations for Resident
Penalty
Summary
The facility failed to obtain and implement the PASARR (Preadmission Screening and Resident Review) findings in a timely manner for a resident with mental health diagnoses and a serious visual impairment. The resident was admitted in September 2020 and had a PASRR Level II evaluation in February 2024, which indicated the need for a mental health evaluation to be completed within 14 days. The evaluation revealed the resident was at risk for self-endangerment, heard voices, and was agoraphobic. Recommendations included increasing the resident's antipsychotic medication, referring to a psychiatric prescriber for medication management, and exploring resources for the visually impaired. However, the facility did not receive a revised copy of the evaluation after requesting it due to incorrect information in the initial report. Interviews with facility staff revealed that the PASARR assessments were typically sent to the facility within a month after completion, but the facility did not notify the evaluator that they had not received the results. The staff responsible for receiving and reviewing the PASARR assessments did not follow up adequately to ensure the recommendations were implemented. Consequently, the interdisciplinary team did not review the recommendations, and the resident's care plan was not updated to include the suggested interventions. This oversight placed the resident at risk for inadequate mental health resources and support.
Failure to Implement Restorative Program for Resident
Penalty
Summary
The facility failed to ensure a resident received a restorative program as recommended by occupational therapy (OT) for maintaining and improving range of motion (ROM). The resident, who was admitted in July 2023 with a diagnosis of stroke, was discharged from skilled therapy with instructions for staff to assist in maintaining strength, endurance, and improving ROM. This included the use of a resting hand splint and exercises with elastic bands and weights. However, there was no evidence in the resident's records that the restorative program was implemented as per the OT's referral from July 2024. Interviews with staff confirmed that the program was not carried out, and the resident reported decreased ROM and lack of assistance with ROM exercises. Observations also noted the absence of the prescribed splint.
Failure to Act on Pharmacy Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure timely action on pharmacy recommendations for a resident with heart disease, who was prescribed multiple blood-thinning medications: Eliquis, clopidogrel, and cilostazol. Pharmacy recommendations were made on three separate occasions to evaluate the concurrent use of these medications and consider discontinuing clopidogrel and cilostazol. However, there was no documented response from the resident's physician for the first two recommendations, and the third recommendation was only referred to a cardiologist without further action. Staff interviews revealed that the facility disbursed the recommendations to the appropriate physicians, but there was no explanation for the lack of timely response. Additionally, the resident was prescribed sertraline, an antidepressant, and pharmacy recommendations were made for a gradual dose reduction (GDR) or a rationale for not implementing a GDR. Despite multiple requests, there was no response documented in the resident's clinical record. Staff acknowledged that the resident's outside physician did not respond to requests in a timely manner, requiring up to four requests for a single recommendation. This inaction placed the resident at risk for an adverse medication regimen.
Failure to Monitor and Adjust Medication for Resident with Loose Stools
Penalty
Summary
The facility failed to ensure appropriate monitoring and dosing of medications for a resident admitted with a diagnosis of cerebral hemorrhage. The resident experienced consistent loose stools and expressed concerns about bowel incontinence to CNAs and an LN, although the resident could not recall specific staff members. A CNA confirmed the resident's consistent soft or loose bowel movements and reported these concerns to the charge nurse multiple times. Despite this, the resident's bowel care task record showed only one normal bowel movement in the past 30 days, with the rest documented as soft or loose. The resident had a physician's order for Senna-Docusate Sodium, a laxative, to be administered twice daily for constipation. The DNS stated that CNAs should inform the charge nurse of any concerns, and the charge nurse should review the record and inform the practitioner, who should adjust medications as needed during weekly visits.
Failure to Provide Working Call Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathrooms of two residents, placing them at risk for the inability to call for assistance. Resident 20, who was admitted in August 2020 with a diagnosis of heart failure and was cognitively impaired, was observed without an emergency call light cord in their bathroom. Despite being monitored for self-transfers to the bathroom, the call light cord was missing from 2/9/25 and was not replaced until 2/11/25. Staff 12, the Maintenance Director, confirmed the absence of the call light cord, and Staff 13, the Maintenance Assistant, noted that the issue was not reported in the maintenance log. Similarly, Resident 9, admitted in 2019 with diabetes, also lacked an emergency call device in their bathroom. The care plan indicated that Resident 9 required assistance for bathroom transfers and should not be left alone. The absence of the call light cord was verified by Staff 12, and Staff 13 confirmed that the need for replacement was not logged. The Administrator was aware of the missing call light cords for both residents but did not ensure their replacement until two days after the issue was identified.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a non-pressure skin wound, leading to a deficiency. The resident was admitted with a contusion and an open wound on the right lower leg, which was managed with a wound vacuum. However, the facility did not consistently document or assess the wound as required by their Skin Integrity policy. The resident's care plan included monitoring and documenting the wound's condition, but there was no evidence of weekly assessments for size, color, odor, exudates, or pain. Additionally, a physician's order for wound care was not entered into the Treatment Administration Record (TAR), and there was a lack of documentation indicating that wound care was completed on specific dates. The resident's condition worsened, with the wound becoming necrotic and infected, leading to sepsis and the need for debridement. The resident reported increased pain when the wound vacuum was removed, and the facility staff failed to maintain adequate wound treatment supplies. Staff interviews revealed inconsistencies in wound care practices, with some staff unable to recall if care was provided and others indicating that assessments were not consistently performed. The facility's failure to adhere to its own protocols and physician orders contributed to the deterioration of the resident's wound condition.
Inadequate Pain Management for Resident with Chronic Pain
Penalty
Summary
The facility failed to provide appropriate and timely pain management for a resident with chronic pain conditions, including fibromyalgia, polyneuropathy, arthritis, and an open wound. The resident was admitted in May 2024 and was on a pain medication therapy plan that required staff to administer medications as ordered, review pain medication efficacy every shift, and respond to any complaints of pain. However, the resident frequently experienced delays in receiving PRN pain medications, sometimes waiting two to three hours, which led to increased pain levels and affected their daily activities. In August and September 2024, the resident's pain management was inconsistent, with documented pain levels ranging from four to ten on a zero to ten scale. The resident reported that medications were not delivered timely, and there were instances where the facility did not have the necessary lidocaine for wound pain management. Staff interviews confirmed that the resident often complained about not receiving PRN pain medications promptly, and there were issues with a specific CMA being confrontational and delaying medication administration. Despite being aware of the resident's complaints, the facility administration and nursing staff did not take adequate steps to address the issue. A former LPN confirmed the absence of lidocaine on a specific date, and a CNA reported frequent complaints from the resident about delayed medication. The facility administrator and DNS were unaware of the resident's concerns, indicating a lack of communication and oversight in ensuring timely pain management for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 131 citations issued within 25 miles in the last 12 months — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Dallas Retirement Village Health Center | 7.7 mi | ★★★★★ | 11 | 0 |
| Avamere Transitional Care At Sunnyside | 8.7 mi | ★★★★★ | 0 | 0 |
| Salem Transitional Care | 11 mi | ★★★★★ | 2 | 0 |
| Windsor Health And Rehabilitation | 11 mi | ★★★★★ | 6 | 0 |
| Tierra Rose Care Center | 13 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Independence Health And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.