Rehabilitation Centers of Independence West Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, review of the facility computerized call light response times, and facility policy review, the facility failed to answer resident call lights in a timely manner for four of five residents reviewed. (Resident #4, #5, #6, #7).The facility reported a census of 56 residents. Findings include:1.The MDS (Minimum Data Set) dated 3/3/2026 reported Resident #4 had no cognitive impairment and had diagnoses including compression fracture, anxiety and diabetes. The resident transferred from one surface to another with staff assistance and a stand up lift. Observation on 3/31/2026 revealed the resident's call light on from approximately 7:37 a.m. until 8:00 a.m. At 7:55 a.m. the resident sat at the edge of the bed and indicated he needed to use the restroom. At 8:00 a.m. staff entered the room to assist him. A review of the computerized call light audit revealed the resident's call light activated at 7:35 a.m. and remained on for 24 minutes. The resident reported it often…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid (CMS) Services Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to accurately code the use of medication on the Minimum Data Set (MDS) Assessment for 1 of 5 residents sampled (Resident #1); and failed to accurately code a determination of serious mental illness as identified on the Preadmission Screening and Resident Review (PASRR) for 1 of 1 residents sampled (Resident #18). The facility identified a census of 51 residents.Findings include:1.Resident #1's MDS dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 7 out of 15 indicating a severe cognitive impairment. The MDS documented Resident #1 received anticoagulant (medication that prevent blood from clotting) and antiplatelet (medication that makes the blood less sticky by stopping platelets from clumpting together) medications.The September and October 2025 Electronic Medication Administration Records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, policy review and resident and staff interviews the facility failed to follow Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed for EBP (Resident #14). The faciltiy reported a census of 51 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #14, dated 9/9/25, documented the resident had an indwelling catheter. During an interview on 12/8/25, the resident reported he had an indwelling catheter. An observation at the same time revealed the EBP poster on the resident's door and a chest of drawers right outside his door. During an observation on 12/10/25 at 1:31 PM, Staff A, Certified Nursing Assistant (CNA), entered the room to empty the catheter drainage bag. She performed hand hygiene and donned gloves. She proceeded to empty the drainage bag. She did not don a gown as required by EBP. During an interview on 12/10/25 at 1:38 PM, the MDS Coordinator acknowledged there was an EBP poster on the resident's door, the chest of drawers outside the room contained the required PPE, including gowns, and she would expect Staff A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and resident interview, the facility failed to maintain a clean, comfortable and homelike environment. The facility reported a census of 56 residents. Findings include: 1. Observation on 8/11/2025 at 9:00 A.M. included: a. A Hall - Wall paper border above hand rail partially removed, peeling in multiple areas. Hall carpet with a large amount of dark stains and blackened colored areas. b. A Hall - room [ROOM NUMBER], #5 - Room carpet with moderate amount of dark stains. c. C Hall - room [ROOM NUMBER], #27, #36 - Room carpet with moderate amount of dark stains. 2. Observation on 8/11/25 at 8:15 A.M. revealed the following: The center hall carpet that went into the service hallway and the kitchen revealed darkened, blackish discoloration on the carpet with areas of solid blackened spots that measured the width of the doors. The carpet leading to the dining room from the center hallway was darkly discolored with blackened spots that measured the width of the double doors.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interviews, the facility failed to follow physician orders for one of three residents reviewed (Resident #2). The facility reported a census of 56 residents. Findings include:Resident #2's MDS (Minimum Data Set) dated 7/18/2025 revealed he had no cognitive impairment, had diagnoses including diabetes, absence left toes, anemia, heart failure, renal insufficiency, hypertension and had diabetic foot ulcers. The Care Plan identified the resident had a risk for alteration in skin integrity related to type two diabetes and other circulatory complications. It directed staff to administer treatments per physician orders, encourage good nutrition and hydration in order to promote healthier skin, and observe skin with ADL's (activities of daily living). A Wound Clinic Note dated 7/31/2025 included an order to provide one serving of Prostat AWC (advanced wound care), a protein supplement, one serving daily. Protein to assist with wound healing.On 8/12/2025 at 12:50 Staff B, DON (Director of Nursing) reported a staff nurse missed the wound clinic order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, review of computerized call light response times, and facility policy review the facility failed to answer resident call lights in a timely manner for two of three residents reviewed (Resident #1, #6). The facility failed to have the call light within reach for one of seven residents reviewed (Resident #5). The facility reported a census of 56 residents. Findings include:1.The MDS (Minimum Data Set) dated 7/2/2025 reported Resident #5 had severe cognitive impairment and had diagnoses including diabetes, history of falls and fracture of the left humerus. The MDS indicated the resident had a fall with no injury since the previous assessment. The resident's Care Plan directed staff to assist the resident with transfers and ambulation with the use of a gait belt, and ensure the call light is within reach. Observation on 8/11/2025 at 9:10 a.m. revealed Resident #5 seated in her room in a recliner with a bedside table at her right side. The call light sat on the bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, and record review the facility failed to prevent financial exploitation for 1 out of 1 residents reviewed for allegations of abuse (Resident #2). The facility identified a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/14/25, listed diagnoses for Resident #2 which included anemia, atrial fibrillation, neurogenic bladder, paraplegia, and pressure ulcer. The MDS stated the resident required set up assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating cognitively intact. Review of a document provided by Resident #2 to the facility revealed a twenty dollar electronic funds transfer to Staff A, Certified Nursing Assistant (CNA) on 2/19/25 at 9:01 PM. During an interview on 4/16/25 at 11:00 AM Resident #2 stated it was late February and I was warming something up in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interviews, and facility policy review the facility failed to report an allegation of abuse to the proper agency in a required time frame for 1 of 1 allegations of abuse reviewed (Resident #2). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 1/14/25, listed diagnoses for Resident #2 which included anemia, atrial fibrillation, neurogenic bladder, paraplegia, and pressure ulcer. The MDS stated the resident required set up assistance from staff for toileting hygiene, showering, dressing, personal hygiene, and transferring. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating cognitively intact. Review of a summary incident provided by the facility revealed Resident #2, was a resident of the facility from 1/7/2025 to 3/28/2025. After discharging to home, Resident #2 called the facility to report that he transferred $22 to a facility caregiver, Staff A, Certified Nursing Assistant (CNA) by Pay Pal at the end of February. Resident #2 reports…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interview, the facility failed to provide each resident with a palatable, well balanced diet that takes into consideration the preferences of each resident. (Resident #14). During an observation of a meal, the facility failed to maintain cold foods below 41 degrees, obtain temperatures and serve the correct portion size of pureed meals. The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15 and had the following diagnoses: Diabetes Mellitus, Arthritis, and [NAME]-[NAME] Syndrome. The MDS also identified Resident #14 to be totally dependent on staff assistance with showers, toileting, lower body dressing, the MDS also identified Resident #14 required substantial/maximal assistance with upper body dressing and transfers. Interviews with Resident #14 revealed the following: 11/12/24 at 9:43 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 48 residents. Findings include: In an observation on 11/13/24 at 1:13 PM Staff A, Laundry/Housekeeping donned gloves, failed to put on a gown, removed the laundry bin lid and put table cloths and cloth napkins in the washing machine. She then removed the gloves, shut the machine door, and started the washer. In an interview on 11/13/24 at 1:04 PM Staff A explained clothes are collected in a bin and sorted into containers. Staff wear gloves for sorting regular laundry and wear a gown, goggles, and gloves for isolation items. Isolation is done at the very end of the day. She further explained some residents have family wash their items, but the facility washes everyone's towels, sheets, dining linens, etc. In an interview on 11/13/24 at 1:16 PM the Environmental Supervisor explained she expected gloves are to be worn when sorting soiled laundry unless it is something from an isolation room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 7 resident's sampled (Resident #49). The facility identified a census of 55 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 7 indicating severe cognitive loss. The Resident required extensive assistance of two staff for bed mobility, transfer, dressing, and toilet use. The MDS listed a diagnosis of diabetes mellitus. The Care Plan dated 8/15/23 documented Resident #49 had a diagnosis of diabetes mellitus and directed the staff to monitor/document/report signs and symptoms of hyperglycemia (hyperglycemia is excessively high blood sugar which can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interview, the facility failed to complete a full assessment on a resident that exhibited confusion with a blood sugar of 409 for 1 of 5 residents sampled (Resident #49). The facility identified a census of 55 residents. Findings include: Resident #49's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) Score of 7 indicating severe cognitive loss. The Resident required extensive assistance of two staff for bed mobility, transfer, dressing, and toilet use. The MDS listed a diagnosis of diabetes mellitus. The Care Plan dated 8/15/23 documented Resident #49 had a diagnosis of diabetes mellitus and directed the staff to monitor/document/report signs and symptoms of hyperglycemia (hyperglycemia is excessively high blood sugar which can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff and resident interview's the facility failed to answer call lights in a timely fashion for 1 of 7 resident reviewed (Resident #18). The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #18 dated 9/26/23, listed diagnoses of diabetes mellitus, arthritis, and falls. The MDS reflected a Brief Interview of Mental Status (BIMS) score of 15, indicated intact cognition. The MDS identified Resident #18 required extensive assist of one staff for transferring and dressing. The MDS continued to reflect she needed set up assistance for eating. The Care Plan for Resident #18 reflected a target date of 1/15/24, revealed She wanted to eat meals in her room. The Care Plan identified a goal she will maintain her daily preferences with staff assistance. On 10/17/23 at 8:06 AM, Resident # 18 sat in her recliner. Resident #18's tray table held her breakfast tray and sat out of her reach by several inches. She reported she turned on her call 15 minutes ago due to her inability to reach her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.