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Complaint Investigation

Independence Rehab And Nursing

February 26, 2026 · Philadelphia, PA · 600 W Cheltenham Avenue
Citations 2
CMS Rating 1/5
Beds 255
Provider ID 395330
Healthcare Facility
Independence Rehab And Nursing
Philadelphia, PA  ·  View full profile →
Inspection Summary

Independence Rehab and Nursing in PHILADELPHIA, PA — inspection on February 26, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0657
Resident Assessment and Care Planning Deficiencies

Review of nursing note dated January 30, 2026 at 2:25 PM, revealed the resident was found smoking

stating he would beat him up.

Continued review of nursing notes revealed a note dated February 4/2026 at 11:36 PM, the resident remained on a Leave of Absence (LOA). A phone call was placed to follow up, but there was no answer. A message was left for the responsible party.

Review of Resident R1's care plan revealed multiple identified risk areas beginning December 17, 2025, including risk for impaired skin integrity, self-care deficits with expected ADL decline, risk for adverse medication reactions related to medication use, and discharge planning needs.

Discharge planning was initiated upon admission, with goals to provide community resource information and ensure appropriate support systems are in place prior to discharge.

The care plan further identifies diabetes management goals to prevent complications, continued monitoring for medication-related adverse effects, and fall risk with interventions to anticipate and meet resident needs.

Additional problem areas include potential oral/dental health issues and nutritional concerns related to abnormal labs, heart disease, diabetes, and a history of high added-sugar dietary patterns.

Behavioral concerns were added to the care plan on January 12, 2026, following an incident in which the resident punched another resident.

The care plan reflects potential for physical and verbal aggression, as well as smoking-related behaviors. On February 4, 2026, a self-determination focus was added addressing the resident's choice not to follow facility smoking rules, with a goal for the resident to discuss and understand the potential negative consequences of noncompliance.

Continue review of Resident R1's care plan revealed that there was no care plan developed for wandering behaviors or elopement risk.

Interview with Social Worker, Employee E3 on February 26, 2026 at 08:58 a.m. confirmed she was familiar with the resident and spoke with the resident on January 20, 2026 regarding the facility's Leave of Absence (LOA) policy.

She informed the resident that he could not go out that day because the physician was not available to provide consent.

Employee E3 described the resident as someone who frequently expressed a desire to leave the facility. At the time of that discussion, she stated she was unaware that the resident had been identified as an elopement risk.

She further indicated she was not aware that the care plan had been updated to reflect elopement risk status. 28 Pa.

Code 201.18(b) Management 28 Pa.

Code 211.12(c)(d)(5) Nursing Services

395330 02/26/2026

Independence Rehab and Nursing 600 W Cheltenham Avenue Philadelphia, PA 19126

Review of Resident R1's nursing notes dated February 3, 2026, revealed that

February 4, 2026, which revealed that the resident left the faciity on leave of absence at

contact resident via phone with no response.

Social service director contacted the shelter were resident previously resided but was not located.

Review of the Leave of Absence log maintained at the front desk, where residents and family sign out when leaving the facility, revealed the following:On February 3, 2026, Resident R1 left the facility at 10:20 AM and returned at 3:20 PM, accompanied by (his/her) brother.On February 4, 2026, Resident R1 again left the facility at 11:05 AM, also accompanied by (his/her) brother.

Resident did not return Interview with Medical Director Employee E4 on February 26, 2025, at 10:50 a.m. stated that he does not write blanket orders for Leave of Absence (LOA). He indicated that it would be highly irregular to issue an LOA order on the same day a resident was admitted to the facility. He explained that an order should be written each time a resident leaves the facility.

The Medical Director further confirmed that if a resident is identified as an elopement risk, the resident should not leave the facility without staff supervision. He stated that he would not give an order permitting a resident identified as an elopement risk to leave the facility independently.

Interview with the Director of Nursing (DON)on February 26, 2026, at 11:30 a.m.

Employee E2 stated that when residents leave the facility, it is considered a day pass.

The DON, Employee E2 reported that documentation for LOA/day passes is limited to the resident signing out.

She stated that for one-day passes, there is no requirement for formal documentation, education, or medication reconciliation.

While nurses may verbally speak with the resident or escort prior to departure, she indicated that this communication does not require documentation.

Interview with Social Worker, Employee E3 on February 26, 2026, at 8:55 a.m., confirmed she was familiar with Resident R1 and had spoken with him on January 20, 2026, regarding the facility's Leave of Absence policy.

She stated that on that date, the resident was not allowed to leave because the physician was unavailable to provide consent.

Employee E3 stated not being aware that the resident had been identified as an elopement risk.

Employee E3 further reported that she was unfamiliar with the facility's policies regarding elopement and Leave of Absence procedures. 28 Pa Code 201.14 (a)(c) Responsibility of Licensee 28 Pa.

Code (b)(1) Management 28 Pa.

Code 211.12 (c)(d)(5) Nursing Services

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PHILADELPHIA, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Independence Rehab and Nursing or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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