Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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) |
|---|---|---|---|---|
| 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 |
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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 August 2026) and official state health department websites.