Independence West: Missed Wound Care Orders - IA
The oversight at Rehabilitation Centers of Independence West Campus lasted nearly two weeks before administrators discovered the error during a federal inspection on August 12.
Resident #2 had multiple serious health conditions including diabetes, heart failure, and diabetic foot ulcers. He was missing toes on his left foot. His care plan specifically identified him as having a high risk for skin problems related to his diabetes and circulation issues.
On July 31, a wound clinic ordered one daily serving of Prostat AWC, an advanced wound care protein supplement designed to promote healing. The order appeared in clinical notes that day.
Staff G, a licensed practical nurse, admitted to inspectors she had completely missed the physician's order. She worked at the facility for eight years and was responsible for following wound clinic instructions for the resident.
"Staff G revealed she missed the Prostat order from the wound clinic, it was considered an order, and did not know how she missed it," inspectors wrote.
The facility's Director of Nursing discovered the problem during the federal inspection. She told inspectors at 12:50 p.m. that "a staff nurse missed the wound clinic order for Prostat. It was hidden in the note dated 7/31/2025."
For nearly two weeks, the diabetic resident went without the prescribed protein supplement while his foot ulcers remained untreated according to physician orders.
The resident's medical assessment from July 18 showed he had no cognitive impairment and was fully aware of his care. His diagnoses included diabetes, anemia, heart failure, kidney problems, and high blood pressure in addition to the diabetic foot ulcers and missing toes.
His care plan directed staff to follow all physician treatment orders, encourage proper nutrition and hydration to promote healthy skin, and monitor his skin condition during daily care activities. The missed protein supplement order violated these care requirements.
The facility's own policy manual, revised in July 2023, required staff to "correctly and safely receive/transcribe physician's orders so correct order can be followed/administered." The policy emphasized ensuring "patient medications, treatments, and plan of care are in accordance with the licensed providers orders."
Staff G's failure to implement the wound clinic order directly contradicted these written procedures.
The Director of Nursing only entered the missed order into the resident's medical record on the day of the inspection, after inspectors identified the problem. She also notified the physician that day about the oversight.
Federal inspectors classified the violation as having caused minimal harm or potential for actual harm to residents. The facility reported a census of 56 residents at the time of inspection.
Protein supplements like Prostat AWC are specifically formulated to support wound healing in patients with compromised circulation and diabetes. The supplements provide concentrated nutrition that damaged tissue requires for repair.
For diabetic patients with foot ulcers, delayed healing can lead to serious complications including infection, tissue death, and potential amputation. The resident had already lost toes on his left foot, making proper wound care critical.
The inspection occurred in response to a complaint about care at the facility. Inspectors reviewed three residents' cases and found the medication order failure affected one of them.
Staff G's admission that she didn't understand how she overlooked the order raised questions about the facility's systems for tracking and implementing physician instructions. The eight-year veteran nurse's confusion suggested potential gaps in the facility's order management procedures.
The missed order remained undiscovered for 12 days until federal inspectors arrived to investigate complaints about the facility's care standards.
The Director of Nursing's description of the order being "hidden" in clinical notes pointed to possible documentation problems that could affect other residents' care. If experienced nursing staff routinely missed physician orders embedded in clinical notes, other treatment failures might go undetected.
The resident continued living at the facility with his multiple chronic conditions and healing wounds, now finally receiving the protein supplement his doctor had ordered nearly two weeks earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rehabilitation Centers of Independence West Campus from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Rehabilitation Centers of Independence West Campus
- Browse all IA nursing home inspections
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Rehabilitation Centers of Independence West Campus in Independence, IA was cited for violations during a health inspection on August 12, 2025.
Resident #2 had multiple serious health conditions including diabetes, heart failure, and diabetic foot ulcers.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Rehabilitation Centers of Independence West Campus?
- Resident #2 had multiple serious health conditions including diabetes, heart failure, and diabetic foot ulcers.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Independence, IA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Rehabilitation Centers of Independence West Campus or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 165303.
- Has this facility had violations before?
- To check Rehabilitation Centers of Independence West Campus's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.