Inspection Report Summary
The most recent inspection on March 12, 2025, identified deficiencies related to the facility’s failure to notify a resident’s physician of all injuries sustained after a fall, including broken teeth and facial injuries. Earlier inspections showed multiple deficiencies involving resident care, notification practices, infection control, staffing levels, and food service quality. Complaint investigations substantiated failures to protect residents from abuse and to notify responsible parties of condition changes, though no fines or enforcement actions were listed in the available reports. Prior reports noted issues with resident dignity, medication administration, and safety measures, with some complaints substantiated but no license suspensions or fines reported. The inspection history indicates ongoing challenges with communication and care coordination, with no clear pattern of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
209% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
118 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the resident's physician of all injuries sustained after a fall for one sampled resident.
Complaint Details
The investigation found that the facility did not notify the physician timely or completely about the resident's fall injuries, including broken implanted teeth and facial bruising. The resident complained of pain that was not fully documented or addressed. The physician and Nurse Practitioner were not fully informed, and follow-up care and documentation were insufficient.
Findings
The facility failed to ensure timely and complete notification to the resident's physician about all injuries sustained after a fall, including broken teeth and facial injuries. Documentation and follow-up care were inadequate, and staff were unaware of or did not report all injuries and pain complaints.
Deficiencies (1)
Failure to notify the resident's physician of all injuries sustained after a fall, including broken teeth and facial injuries.
Report Facts
Facility census: 118
Date of fall: Mar 6, 2025
Medication doses: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Assisted resident after fall, applied pressure to laceration, did not notify provider of all injuries |
| LPN B | Licensed Practical Nurse | Administered PRN hydrocodone, did not notify physician about facial injuries or increased medication use |
| LPN C | Licensed Practical Nurse | Applied steri-strips to laceration, managed swelling, did not notify physician |
| CNA A | Certified Nursing Assistant | Reported resident fall, found resident's teeth on floor, notified LPN A |
| Director of Nursing | Director of Nursing | Interviewed regarding awareness and expectations for fall management and notification |
| Physician | Physician | Interviewed about expectations for notification and care after resident fall |
| Nurse Practitioner | Nurse Practitioner | On-call provider at time of fall, not informed of all injuries |
| Administrator | Administrator | Interviewed about facility expectations for fall management and documentation |
Inspection Report
Routine
Census: 101
Deficiencies: 21
Date: Jan 10, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for the Rehabilitation Center of Independence, including resident rights, care, safety, and quality of services.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, care and assistance with activities of daily living, infection control, medication administration, staffing levels, resident activities, food quality and safety, and regulatory compliance such as social worker qualifications and quality assurance meetings.
Deficiencies (21)
Failed to ensure residents' right to a dignified existence and respectful treatment during care interactions for three residents.
Failed to protect the rights of a resident whose room was changed without prior written notice.
Failed to appropriately address and resolve grievances raised during resident council meetings regarding food, laundry, and shower services.
Failed to ensure appropriate notification following a fall during a transfer for one resident; staff did not notify nurse or physician.
Failed to provide documentation of appropriate notification of pending Medicare benefit changes for one resident.
Failed to notify resident and representative of facility-initiated emergency transfer to hospital for one resident.
Failed to provide written notice of facility's bed-hold policy upon transferring a resident to hospital for one resident.
Failed to ensure accuracy of skin assessment; documentation did not reflect actual skin condition for one resident.
Failed to obtain physician ordered urinalysis in a timely manner for one resident.
Failed to provide necessary nursing care and services for activities of daily living including bathing, toileting assistance, and adaptive eating equipment for multiple residents.
Failed to provide meaningful activities on weekends and failed to get one resident out of bed for activities desired.
Failed to identify and implement necessary care and services to address needs of diabetic resident, including blood glucose monitoring and insulin administration, resulting in hospitalization.
Failed to ensure residents smoked only in designated areas and failed to supervise residents while smoking.
Failed to provide perineal care in a manner to prevent urinary tract infection for one resident.
Failed to ensure residents fed by enteral means received appropriate treatment and services including supplemental tube feedings as ordered.
Failed to maintain adequate nursing staffing levels to meet residents' needs, routinely falling below established benchmark of 2.8 nursing hours per patient per day.
Failed to ensure pureed diets were followed according to the menu, including omission of pureed bread.
Failed to provide palatable foods per resident preferences for taste and temperature; food often served cold and late, with ongoing resident complaints.
Failed to employ a qualified licensed social worker as mandated for facilities with more than 120 beds.
Failed to provide and implement an infection prevention and control program including proper hand hygiene and enhanced barrier precautions for residents with wounds and indwelling devices.
Failed to hold regular Quality Assurance Performance Improvement Plan (QAPI) meetings with required members and documentation.
Report Facts
Census: 101
Nursing staff hours per patient per day: 2.03
Nursing staff hours per patient per day: 2.72
Minimum nursing staff hours per patient per day: 2.8
BIMS score: 13
BIMS score: 14
BIMS score: 15
BIMS score: 15
BIMS score: 14
BIMS score: 14
BIMS score: 2
Blood sugar: 541
Blood sugar: 290
Shower frequency: 2
Shower frequency: 1
Shower frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA AA | Restorative Nursing Aide | Named in findings related to dignity, feeding assistance, toileting assistance, and inappropriate behavior |
| LVN DD | Licensed Vocational Nurse Treatment Nurse | Named in findings related to skin assessment, wound care, and fall incident |
| CNA BB | Certified Nurse Aide | Named in disagreement with RNA AA regarding perineal care |
| CMA CC | Certified Medication Aide | Named in interview regarding resident sleeping in wheelchair |
| LPN FF | Licensed Practical Nurse | Named in interview regarding transfer notification and smoking supervision |
| CMT HH | Certified Medication Technician | Named in assisting resident with toileting and interview about care |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility policies, staffing, and deficiencies |
| Director of Nursing | Director of Nursing (DON) | Named in multiple interviews regarding facility policies, staffing, and deficiencies |
| Social Worker | Social Worker (SW) | Named in interview regarding licensing and notification letters |
| Activity Director | Activity Director (AD) | Named in interview regarding resident activities and weekend programming |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Named in interview regarding resident transfer fall incident |
Inspection Report
Routine
Census: 91
Deficiencies: 16
Date: Jun 13, 2023
Visit Reason
Routine inspection of the Rehabilitation Center of Independence to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to notify resident's responsible parties of condition changes, failure to provide required Medicare notices, resident-to-resident abuse incident, failure to provide timely transfer and bedhold notifications, incomplete quarterly assessments and MDS transmissions, incomplete lab services, improper respiratory equipment maintenance, inadequate dietary assessments and preferences, unsanitary food service conditions, incomplete infection control program and isolation precautions, failure to post nurse staffing information daily, narcotic medication administration and count discrepancies, and incomplete pharmacist medication regimen reviews.
Deficiencies (16)
Failure to notify resident's responsible party of changes in condition or medication orders for Resident #25.
Failure to provide Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents discharged from Medicare Part A.
Resident-to-resident abuse incident resulting in injury to Resident #18 caused by Resident #78.
Failure to provide timely written notification of transfer and reason for transfer to hospital for Residents #42, #71, and #87.
Failure to provide written bedhold policy to Residents #42, #71, and #87 when transferred to hospital.
Failure to complete quarterly Minimum Data Set (MDS) assessment for Resident #40.
Failure to transmit MDS assessments timely to CMS for Residents #31, #86, and #43.
Failure to complete ordered laboratory services for Residents #40 and #61.
Failure to ensure oxygen tubing and equipment was clean, stored properly, and changed per physician orders for Residents #7, #62, and #87.
Failure to maintain sanitary food service environment including walk-in refrigerator and freezer floors, utensils, food preparation equipment, and incomplete hot food temperature documentation.
Failure to provide and implement a comprehensive infection prevention and control program including waterborne pathogen prevention and isolation precautions for Resident #28 with MDRO infection.
Failure to provide pneumococcal vaccine assessments, education, and administration for Residents #355, #28, and #71.
Failure to provide required 12 hours of in-service training for CNAs and LPNs including abuse prevention, dementia care, and resident rights.
Failure to sign out narcotic medication before administration, incomplete narcotic count signatures, presigning narcotic count sheets, inaccurate narcotic counts, and inaccurate narcotic count signature page.
Failure to post nurse staffing information daily in a prominent, accessible location for residents and visitors.
Failure to ensure medication refrigerator temperature was checked daily and maintained within required range.
Report Facts
Facility census: 91
Narcotic count missing signatures: 44
Narcotic count discrepancies: 1
RN staffing missing days: 17
Temperature log entries: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in narcotic medication administration and count findings |
| LPN B | Licensed Practical Nurse | Named in narcotic medication count discrepancy and count sheet presigning |
| DON | Director of Nursing | Named in multiple findings including narcotic counts, MRR follow-up, infection control, and staffing |
| Regional Nurse Consultant B | Regional Nurse Consultant | Named in staffing and infection control findings |
| CNA A | Certified Nursing Assistant | Named in resident abuse incident |
| LPN A | Licensed Practical Nurse | Named in resident abuse incident and narcotic count findings |
| Nutrition Services Manager | Named in dietary assessment and food preference findings | |
| MDS Coordinator A | MDS Coordinator | Named in MDS transmission and assessment findings |
| MDS Coordinator B | MDS Coordinator | Named in MDS transmission and assessment findings |
| LPN E | Licensed Practical Nurse | Named in oxygen tubing and narcotic count findings |
| LPN G | Licensed Practical Nurse | Named in dietary and staff education findings |
| CNA C | Certified Nursing Assistant | Named in staff education findings |
| CNA G | Certified Nursing Assistant | Named in staff education findings |
| LPN D | Licensed Practical Nurse | Named in staff education findings |
| CNA E | Certified Nursing Assistant | Named in staff education findings |
| LPN H | Licensed Practical Nurse | Named in medication refrigerator temperature findings |
| Administrator | Named in staffing and infection control findings | |
| DOM | Director of Maintenance | Named in infection control and waterborne pathogen prevention findings |
| IP | Infection Preventionist | Named in infection control findings |
| CMT A | Certified Medication Technician | Named in dietary complaint |
| Physician B | Physician | Named in resident abuse incident |
| Social Services Director | Named in Medicare notice findings |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 2
Date: Jun 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's responsible party of changes in condition and medication, and failure to protect a resident from resident-to-resident abuse.
Complaint Details
The complaint investigation found substantiated failure to notify the responsible party of Resident #25 about changes in condition and medication. The investigation also substantiated that Resident #78 struck Resident #18 causing multiple injuries, but did not substantiate abuse due to Resident #78's cognitive impairments limiting willful intent.
Findings
The facility failed to notify the responsible party of Resident #25 about significant changes in condition and medication orders. Additionally, the facility failed to prevent resident-to-resident abuse when Resident #78 struck Resident #18 with a wooden back scratcher, causing multiple injuries. The facility substantiated the incident but did not classify it as abuse due to cognitive impairments of Resident #78.
Deficiencies (2)
Failure to notify Resident #25's responsible party of medication changes, ordered tests, and change in condition.
Failure to ensure Resident #18 was free from resident-to-resident abuse resulting in multiple injuries.
Report Facts
Residents affected: 1
Residents affected: 1
Facility census: 91
Memory care unit residents: 14
Laceration size: 1.9
Lacerations count: 3
Staples used: 5
Staples used: 10
Interview dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | LPN | Stated family should be notified of changes in resident condition and treatment |
| Licensed Practical Nurse F | LPN | Stated nurse caring for resident should notify family of changes |
| Director of Nursing | DON | Confirmed family notification requirements |
| Regional Nurse Consultant | RNC | Confirmed family notification requirements |
| Licensed Practical Nurse A | LPN | Responded to abuse incident and conducted assessments |
| Licensed Practical Nurse B | LPN | Assigned nurse on dementia unit during incident |
| Certified Nursing Assistant A | CNA | Discovered abuse incident and intervened |
| Psychiatric Nurse Practitioner A | Psych NP | Interviewed regarding dementia residents and behavior unpredictability |
| Assistant Director of Nursing | ADON | Provided information on staffing and incident response |
| Physician B | Physician | Provided medical background on residents involved |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: Feb 22, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #1 inappropriately touched Resident #2's genitalia on 2/15/23.
Complaint Details
The complaint investigation substantiated that Resident #1 touched Resident #2 inappropriately on 2/15/23. The facility promptly separated the residents, notified the Director of Nursing, Administrator, Nurse Practitioner, guardians, and state authorities. Resident #1 was placed on 15-minute checks and later transferred to another facility. Resident #2 could not recall the incident. Staff were educated on abuse prevention.
Findings
The facility failed to protect one resident from physical abuse by another resident. The incident was immediately addressed by separating the residents, notifying appropriate parties, and providing staff education. Resident #1 was placed on 1 to 1 supervision and later transferred to another facility. No injuries were reported and the Nurse Practitioner assessed both residents.
Deficiencies (1)
Failed to protect one sampled resident from physical abuse when another resident inappropriately touched the resident's genitalia.
Report Facts
Residents present: 98
15-minute checks duration: 39
Medication dosage: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Notified of the incident and provided interview details about the incident and facility response | |
| Licensed Practical Nurse (LPN) A | Witnessed the incident and described the facility's response | |
| Nurse Practitioner | Assessed both residents immediately after the incident and prescribed medication for Resident #1 |
Inspection Report
Census: 95
Deficiencies: 10
Date: Apr 14, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, professional standards of care, activities, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity, failure to meet professional standards of care related to medication administration and monitoring, failure to provide individualized activity programs, failure to investigate and prevent injury, failure to ensure required physician visits, failure to maintain sanitary food service and preparation areas, and failure to establish a comprehensive infection prevention and control program.
Deficiencies (10)
Failure to promote dignity when a cognitively impaired resident was exposed in an incontinence brief and hospital gown visible to the hallway and not dressed daily in appropriate clothing.
Failure to ensure services met professional standards of quality including obtaining physician's orders for cardiac devices and accurate documentation of respiratory assessments and medication administration.
Failure to provide activities to meet residents' needs including lack of individualized activity plans and insufficient activity supplies for cognitively impaired and intact residents.
Failure to provide appropriate treatment and care according to orders, including failure to monitor and assess for signs and symptoms of infection leading to osteomyelitis and partial finger amputation, failure to follow discharge and physician orders for weight monitoring, and failure to notify physician of excessive weight gain.
Failure to ensure an unwitnessed injury to a resident was thoroughly investigated and to immediately put interventions in place to prevent further injury, resulting in a second injury to the resident's finger.
Failure to provide safe and appropriate respiratory care including failure to ensure appropriate supplies for tracheostomy care and failure to transcribe physician's orders for use of BiPAP.
Failure to provide safe, appropriate pain management including failure to accurately document pain medication administration and reconciliation for controlled substances, and failure to document pain assessments and administer scheduled pain medications.
Failure to ensure residents received required physician visits with an alternating personal visit in a rotation of the resident's physician and nurse practitioner.
Failure to procure food from approved sources and maintain sanitary food serving utensils and preparation equipment, including failure to ensure plastic cutting boards were in good condition, failure to separate damaged food stuffs, failure to refrigerate food stuffs when needed, and failure to keep kitchen floor areas clean.
Failure to properly dispose of garbage and refuse by not keeping dumpster lids closed and trash can lids properly covered.
Report Facts
Census: 95
Weight gain: 112.5
Weight gain percentage: 29
Medication administration opportunities missed: 9
Medication administration opportunities missed: 4
Medication administration opportunities missed: 96
Medication administration opportunities missed: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON B | Assistant Director of Nursing | Involved in tracheostomy care and interview regarding medication administration and resident care |
| LPN C | Licensed Practical Nurse | Involved in tracheostomy care and interview regarding medication administration and resident care |
| CMT A | Certified Medication Technician | Interviewed regarding medication administration and resident care |
| DON | Director of Nursing | Interviewed regarding medication administration, resident care, and infection control |
| ADON A | Assistant Director of Nursing | Interviewed regarding resident care and medication administration |
| LPN A | Licensed Practical Nurse | Interviewed regarding medication administration and resident care |
| CNA B | Certified Nursing Assistant | Witnessed resident injury and interviewed about resident care |
| CMT B | Certified Medication Technician | Interviewed regarding medication administration and resident care |
| Medical Director | Interviewed regarding infection control and resident care | |
| Nurse Practitioner | Interviewed regarding resident care and medication administration | |
| Dietary Manager | Interviewed regarding kitchen sanitation and food safety | |
| Therapy Director | Interviewed regarding resident injury and wheelchair safety | |
| MDS Coordinator A | Interviewed regarding supply procurement for tracheostomy care | |
| MDS Coordinator B | Interviewed regarding supply procurement for tracheostomy care | |
| CMT C | Certified Medication Technician | Interviewed regarding resident injury and medication administration |
| LPN D | Licensed Practical Nurse | Interviewed regarding resident injury and wheelchair safety |
| CNA C | Certified Nursing Assistant | Interviewed regarding resident behavior and care |
| AD | Activity Director | Interviewed regarding resident activities and behavior |
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