Independence Rehab and Nursing

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that an allegation of sexual abuse involving Residents R1 and R2 was properly and timely reported to law enforcement for 2 of 8 records reviewed (Resident R1, R2).

Inspectors wroteBased on observation, resident and staff interview, the facility failed to serve food at safe temperatures during meal service one of four nursing units. (4th floor)

Inspectors wroteBased on observations, resident and staff interviews, it was determined that the facility did not provide a safe and homelike environment related to the condition and functionality of resident sinks for four out of nine-bathroom sinks. (First-floor nursing unit). Findings Include:On April 27, 2026, at 9:27 a.m., an interview was conducted with the Maintenance Director, Employee R3, and the Director of Nursing, Employee E2, who confirmed the following observations:room [ROOM NUMBER] had a sink with slow water drainage.room [ROOM NUMBER] had a hole by the Bed B below the windowOn April 27, 2026, at 10:00 a.m., during an interview, Resident R1 reported that the bathroom sink sometimes does not shut off properly and that both faucet knobs must be aligned in order for the water to be turned off. On April 27, 2026, at 10:46 a.m. [...]

Inspectors wroteBased on observations, facility measurements, and staff interviews, it was determined that the facility failed to ensure resident bedrooms provided at least 80 square feet of usable living space per resident for multi-occupancy rooms, excluding toilets, bath areas, closets, lockers, wardrobes, alcoves, and vestibules, for two of two rooms reviewed (rooms [ROOM NUMBERS]). Findings Include:A review of the facility policy titled Room Square Footage, last revised November 1, 2025, revealed under section 4.2 that semi-private resident rooms shall provide a minimum of 80 square feet of usable floor space per resident. On April 27, 2026, at 9:27 a.m. [...]

Inspectors wroteBased clinical record reviews, interviews with residents and staff and reviews of policies and procedures, it was determined for three of eleven residents reviewed that the administrative staff failed to conduct and complete a thorough investigation into an incident of physical altercation between two residents (Resident R1 and Resident R2) and a physical altercation between Resident R1 and nursing staff member (Employee E7).

Inspectors wroteBased on clinical record review, staff interview, review of facility policy and information of alcohol-based hand sanitizer, it was determined the facility failed to adequately supervise and monitor Resident R1. This failure resulted in Resident R1 obtaining and ingesting alcohol-based hand sanitizer on three separate dates resulting in an Immediate jeopardy situation for one out of three residents reviewed (Resident R1).

Inspectors wroteBased on clinical record reviews, and interviews with staff, it was determined the facility failed to implement interventions following prior elopement behavior and failed to revise the care plan to reflect newly identified elopement risk and escalating behavioral for one of one resident reviewed. (Resident R1)

Inspectors wroteBased on review of facility documents, review of clinical records, and interviews with staff it was determined that the facility failed to provide adequate supervision for 1 of 1 sampled resident identified as being at risk for elopement and failed to implement interventions following prior elopement behavior. (Resident R1)

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to provide residents with their requested foods of preferences for five of seven residents interviewed (Residents R3, R4, R5, R6 and R9).

Inspectors wroteBased on review of facility policies, documentation and clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure all allegations of suspected abuse were reported immediately, as required, to the Department of Health for two of three allegations reviewed (Resident R2 and R10).

Inspectors wroteBased on clinical record review, review of information submitted by the facility, review of facility documents, and staff interview, it was determined the facility failed to ensure a resident was free of abuse for one of two residents reviewed (Resident R1). This failure resulted in actual harm to Resident R1. Resident R1 was involved in a physical altercation with a staff member, during which the staff member punched Resident R1 in the face. A reasonable person would determine that a staff member striking a resident with moderate cognitive impairment caused actual harm. Due to the resident's cognitive limitations and dependence on staff for care and protection, the impact of the incident is magnified and places the resident at risk for ongoing psychological trauma. This deficiency was cited as past non-compliance.

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that one resident (Resident R2) was properly assessed by nursing staff and failed to ensure that 2 residents received medications according to physician orders (Resident R5 and R6).

Inspectors wroteBased on observations, facility policy, resident and staff interviews, it was determined that the facility failed to maintain the facility in a safe, clean and homelike condition on two of four nursing units (1st floor [NAME] Unit and 4rth floor nursing unit).

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure complete and accurate clinical record regarding the consumption of a meal for 1 out of 3 residents observed (Resident R5).

Inspectors wroteBased on a review of facility policy, clinical record review, and interviews with resident and staff, it was determined that the facility failed to assist and initiate a discharge plan for a resident who requested to be discharge from the facility for one of three residents reviewed. (Resident R1)

Inspectors wroteBased on observations, review of facility policy, and interview with residents and staff it was determined that the facility failed to ensure that residents were explained their resident rights for four of eleven residents reviewed. (R1, R76, R120, and R178). Findings Include:Review of the facility policy titled Resident Rights undated, reads Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. [...]

Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to provide residents with the ability to file grievances anonymously for four out of four nursing units reviewed. Findings Include: Review of the facility policy titled, Grievance Policy dated November 2016 states, The facilities established grievance policy includes: Notifying the resident individually or through posting of the right to file grievances orally or in writing, the right to file grievances anonymously, the contact information of the grievance official, a reasonable expected time frame for completing review of the grievance, the right to obtain a written decision, the contact of independent entities to whom grievances may be filed (state agency, quality improvement or, state survey agency, state LTC ombudsman). [...]

Inspectors wroteBased on review of facility documentation, and interview with staff it was determined that the facility did not notify the state mental health authority or state intellectual disability authority, promptly after a significant change in the mental condition for three of thirty-three residents reviewed. (R4, R53, R56). Findings Include: Review of Resident R4's psychiatry note from September 2, 2025 stated, [Resident R4] with noted history of schizoaffective disorder in electronic health records system and past psychology note. Resident R4 does not answer appropriately assessment questions and is a poor historian. [Resident R4] was previously prescribed Haldol, but medication was discontinued in 2024, after discontinuation, pt displayed no signs of psychosis. [Resident R4's] medical record includes no documentation confirming schizoaffective diagnosis. [...]

Inspectors wroteBased on observation, review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that a person-centered care plan was developed related to oxygen and PTSD (post-traumatic stress disorder) for two of 33 residents reviewed (Resident R11 and Resident R19) Review of facility's undated policy on Comprehensive Care Plan revealed that under section Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Section Policy Explanation and Compliance Guidelines:1. [...]

Inspectors wroteBased on review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to provide timely pressure ulcer treatment for one of nine residents reviewed (Resident R13). Review of Resident R13's clinical record revealed that Resident R13 was admitted to the facility on [DATE], with diagnoses of but not limited to Hypertension (high blood pressure), Rheumatoid Arthritis (isa chronic autoimmune disease that primarily affects the joints), Hypothyroidism (condition due to deficiency in the thyroid hormone resulting in decreased body metabolism). Review of Resident R13's MDS (minimum data set a federally required resident assessment completed at a specific interval) dated June 26, 2025, revealed that section GG0130. Self-Care C. Toileting hygiene: was coded has dependentant. [...]

Inspectors wroteBased on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to ensure that hot beverages were served at a safe temperature during a resident activity in one of four floors. (Second floor dining room)

Inspectors wroteBased on clinical record review and staff interview, the facility did not ensure that nurse aides received annual performance evaluations to assess competency and performance, as required. Findings Include: An interview was held on September 17, 2025 at 2:45 p.m. with Employee E1 the Nursing Home Administrator. Employee E1 when asked to provide evidence nurse aides were evaluated at least every 12 months. Employee E1 stated, we don't have any nurse aide evaluations. I thought that they needed the required trainings only. Based on the information above, the facility could not provide any nurse aide evaluations during the past 12 months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa.

Inspectors wroteBased on observation, review of facility documentation and staff interview, it was determined that the facility failed to ensure that dietary equipment to maintain hot foods remain in functional capacity.

Inspectors wroteBased on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the Nursing Home Administrator and Director of Nursing effectively and efficiently implemented resources to management incidents of resident abuse and failed to ensure that behavior management resources were implemented for one of seven sampled residents (Residents R148)

Inspectors wroteBased on record review, facility policy review, and staff interviews, the facility failed to develop and maintain an accurate, comprehensive facility-wide assessment.

Inspectors wroteBased on observations, resident and staff interviews, and review of facility policies, it was determined that the facility failed to ensure that residents are treated with dignity and respect for one of 35 residents reviewed. (Resident R183)

Inspectors wroteBased on observation, review of clinical records, staff interview, and review of facility policies, it was determined that the facility failed to ensure that one of 33 residents reviewed was assessed to self-administered medications. (Resident R77)Findings Include: Review of the facility's policy titled Medication Self-Administration revealed that residents are not permitted to retain or self-administer medications in their rooms unless the primary physician writes an order authorizing self-administration and the interdisciplinary team determines the resident is capable of doing so safely. An evaluation of the resident's ability to self-administer must be conducted and documented. The physician's order must be signed and dated prior to self-administration. [...]

Inspectors wroteBased on observation, review of facility policy and interview with residents and staff, it was determined that the facility failed to ensure to maintain privacy for resident's clinical records during medication administration and incontinence care for two of thirty-one residents observed (Resident R168 and R207).

Inspectors wroteBased on observation, review of clinical records and staff interview, it was determined that the facility failed to maintain a safe, clean, and comfortable environment in a manner that promotes a homelike atmosphere for residents for one of 33 residents reviewed (Resident R1 and Resident R62) and on one of four nursing floors. (Third floor)Findings Include:Review of facility policy titled, Resident Rights undated states that the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Further review of the policy states that residents have the right to a 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. [...]

Inspectors wroteBased on observations of care and services, reviews of facility policies and procedures, interview with residents and staff, reviews of facility documentation and clinical records, it was determined that the facility failed to ensure that allegations of verbal abuse, mental abuse and physical abuse were reported promptly and thoroughly investigated for three of thirty-one residents reviewed. (Resident R2, Resident R148, Resident R211 and Resident R45)

Inspectors wroteBased on review of clinical record, review of facility documents, job descriptions and interview with staff it was determined that the facility failed to ensure that a qualified staff performs a wound assessment for one of nine residents reviewed (Resident R13)Review facility job description for licensed nursing staff revealed Job summary qualifications responsibilities duties and tasks of a charged nurse. Further review of the facility's job description for a charged nurse revealed that there was no specific job description for a registered nurse and there was no specific job description for a licensed practical nurse. [...]

Inspectors wroteBased on observations of the physical environment of the building on the first floor, reviews of the pest control operators reports and interviews with staff, it was determined that the facility was not maintaining an effective pest control program.

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility failed to ensure that a medication label was accurate for one of (Resident R3).

Inspectors wroteBased on interviews with staff, review of clinical records, and facility documentation, it was determined the facility failed to protect Resident R112 from Resident R46 who had a history of verbal aggression towards Resident R112. This failure resulted in actual harm to Resident R112 who sustained a closed head injury and a fractured right finger when Resident R46 became physically violent towards Resident R112 for two of 33 resident records reviewed. (Resident R112 and Resident R46)

Inspectors wroteBased on clinical record reviews, interviews with residents and staff, reviews of policies and procedures and food committee meeting minutes, it was determined that for eight of nine residents reviewed, the facility failed to ensure that suitable and nourishing snacks were provided for the residents who wanted to eat at non-traditional times, outside of the scheduled meal service schedule. (Residents R111, R23, R476, R95, R145, R133, R162 and R167).

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on review of clinical records, review of facility policy,and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive care plan related to Resident R46's diagnosis of physical aggression, paranoia, insomnia and Resident R170 needing oxygen therapy for two of 33 resident records reviewed

Inspectors wroteBased on review of clinical records, interviews with staff, and facility policy, it was determined the facility failed to provide treatment and services in accordance with professional standards of practice related to a failure to conduct routine testing to verify therapeudic levels of a seizure medication. The facility failed to clarify the orders when a medication for epilepsy was decreased in error, and failed to inform the physician of a recommended psychotropic dose increase for one of 33 resident records reviewed. (Resident R46 )

Inspectors wroteBased on observations, review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for two of 36 residents reviewed for limited range of motion (Resident R7 and Resident R37).

Inspectors wroteBased on the review of clinical records, observation, facility documentation and interviews with staff, it was determined that the facility failed to ensure that the residents' environment was free of accident hazards, and failed to ensure that hazardous material were not accessible to a resident in one nursing unit of one of three nursing units. (Third floor)

Inspectors wroteBased on clinical record review, interviews with staff and reviews of policies and procedures, it was determined the facility failed to ensure a medication were administered with adequate indications for use and monitoring for two of 33 resident clinical records reviewed (Resident R46 and R83).

Inspectors wroteBased on clinical records review and staff interview, it was determined that the facility failed to obtain a laboratory study as ordered by the physician for one of 33 clinical records reviewed. (Resident R158)

Inspectors wroteBased upon observations, staff interviews, and review of clinical records, it was determined this facility failed to establish and maintain enhanced barrier precautions for one resident of eight resident reviewed (Resident R15).

Inspectors wroteBased on review of facility policies, facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to adequately supervise a resident who was at risk for elopement and failed to ensure that windows were secure on the unit. This failure resulted in an Immediate Jeopardy situation for Resident R1, who exited the building through a third floor window and sustained serious injuries, including bilateral lower extremity fractures and a fracture of the third lumbar spine vertebra for one of three residents. (Resident R1)

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility regarding the elopement of one of three residents reviewed.(Resident R1)

Inspectors wroteBased on staff interviews, review of clinical records and review of facility policy, it was determined that the facility failed to ensure professional standards of practice related to medication administration for one out 3 residents reviewed (Resident R1).

Inspectors wroteBased on staff interviews, review of clinical record and review of facility policy, it was determined that the facility failed maintain complete and accurate clinical records regarding an elopement event for one out of three residents reviewed (Resident R1).

Inspectors wroteBased on review of facility documentation, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that a resident was informed of and allowed to participate in decisions regarding the resident's care and treatment for one of five residents reviewed (Resident R1). Findings Include: Review of Resident R1's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated February 29, 2924, revealed the resident was cognitively intact and had diagnoses of anxiety and depression. Interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the resident recently missed doses of Trazodone, a medication used to help the resident sleep. Resident R1 reported that nursing staff told him the medication was discontinued by the physician but was unable to explain why. [...]

Inspectors wroteBased on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on a review of clinical records and facility documentation, and staff interviews, it was determined the facility failed to implement a complete drug regimen review process for four of 36 residents reviewed (Resident R131, R37, R42 and R123). Findings Include: Review of the undated Consultant Pharmacist Services Provider Requirements Policy revealed, Medication Regimen Reviews (MRR) for each skilled nursing resident at least monthly, communicate to responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected, and other findings related to medication therapy orders at least monthly, review and follow-up to previous month's pharmacy recommendations with the nursing care center staff. [...]

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the failed to ensure complete and accurate documentation related to tuberculosis testing for three of three residents reviewed (Resident R480, R479, R134).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of four dialysis residents reviewed (Resident R148).

Inspectors wroteBased on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to maintain sufficient dietary personnel to complete essential job functions, related to meals being served late.

Inspectors wroteBased on observation, review of facility policy and procedure, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program, related with linen washing and processing, in one of one laundry room in the facility. (laundry room)

Inspectors wroteBased on a review of clinical records, review of facility policies, observations and staff interviews, it was determined that the facility failed to timely assess and consistently provide recommended and/or prescribed treatment and services, to prevent new wound development, promote healing and prevent worsening of existing wounds. This failure resulted in actual harm to Resident R1 who developed new and worsening wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. (Resident R1)

Inspectors wroteBased on the review of employee job description, clinical records and interviews with staff, it was determined that the facility failed to complete a skin assessment according to professional standards of nursing practice. (Employee E4) Findings Include: Review of job description for Unit Manager, revealed that Unit Manager will oversee the medical and personal care of residents and supervise the nurses and other caregivers who interact with the residents on a daily basis in accordance with state and federal regulations to promote high quality of care and service. Responsibilities: Ensures complete and prompt reporting of incidents with follow-up as necessary to Administrator and Director of Nursing. Oversee resident care to promote the highest level of physical, mental and psychosocial functioning possible for assigned unit. [...]

Inspectors wroteBased on observations, review of clinical records, review of facility policy and interviews with staff, it was determined the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for one of four clinical records reviewed (Resident R1).

Inspectors wroteBased on the review of facility policy, interviews with staff, it was determined that the facility failed to ensure that the nursing staff possessed appropriate competencies for tracheostomy care for one of one employee record reviewed. (Employee E5). Findings Include: Review of CDC (Centers for Disease Control and Prevention), Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee recommendations revealed that, Prevention of Person-to-Person Transmission of Bacteria 1. Standard Precautions a. Hand hygiene: [...]

Inspectors wroteBased on a review of clinical records, facility documentation and interview with staff, it was determined that the Nursing Home Administrator and the Director of Nursing did not ensure to effectively manage the facility related to prevention of pressure ulcers and pressure injuries (PU/PI) for one of one residents reviewed (Resident R1)

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to implement proper use of personal protective equipment (PPE) when practicing enhanced barrier precautions during tracheostomy care and failed to follow enhanced barrier precautions as ordered by the physician. One of four resident records reviewed. (Resident R1) Findings Include: Review of an undated facility policy Enhanced Barrier Precaution revealed that Enhanced barrier precautions referred to the use of gown and gloves for use during high-contact resident care activities for resident known to be colonized or infected with a MDRO (Multidrug-resistant bacteria are bacteria that are resistant to three or more classes of antimicrobial drugs.)as well as those at increased risk of MDRO acquisition. [...]

Inspectors wroteBased on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R92 was free from neglect related to a significant medication error. This failure resulted in an Immediate Jeopardy situation for Resident R92 who received 10 units of a fast-acting insulin that was intended for another resident and without proper monitoring following the administration of the insulin for one of 40 residents reviewed. (Resident 92).

Inspectors wroteBased on observations, review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free of medication errors for one of 40 residents reviewed (Resident R92). This failure resulted in an Immediate Jeopardy situation for Resident R92 who was administered 10 units of a fast- acting insulin medication that was intended for another resident.

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not ensure that appropriate notices were provided related to transfer to the hospital/discharge for four of 40 records reviewed (Residents R52, R70, R71, R326).