Independence Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Independence Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 18, 2025

  Based on interview and record review it was determined the facility failed to ensure a resident was transferred as care planned for 2 of 2 sampled residents (#s 2 and 31) reviewed for falls. this placed residents at risk for injury. Findings include: 1. Resident 2 admitted to the facility in 1/2007 with diagnoses including dementia (a group of symptoms affecting cognition, memory and social relationships) and hemiplegia following cerebral infarction (paralysis of one side of the body following a stroke caused by a blood clot in the brain). Resident 2 was non-verbal and unable to be interviewed due to dementia. A review of the Physician Encounter note dated 8/25/24 revealed the resident was transported to the emergency department following a fall on 8/25/24. […]

• No harm, potential for more than minimal, widespreadF908May 11, 2026

  Based on observation, interview, and record review it was determined the facility failed to maintain essential kitchen equipment for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk for food borne illnesses. Findings include:The 12/5/07 manufacturer specifications for the Ecolab Model ES-2000 indicated the dishwasher required a minimum wash and rinse temperature of 120 degrees Fahrenheit and a recommended temperature of 140 degrees Fahrenheit.On 5/7/26 at 12:17 PM, an observation of the facility kitchen revealed the dishwasher temperature gauge was hazed and unreadable. Staff 16 (Registered Dietician) acknowledged the gauge was unreadable. She stated Dietary Manager was on vacation. […]

• No harm, potential for more than minimal, widespreadF727Oct 7, 2022

  Based on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours for 9 days out of 30 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include: Review of the Direct Care Staff Daily Reports from 9/3/22 through 10/3/22 revealed no RN coverage for the following dates: - 9/3/22 - 9/11/22 - 9/17/22 - 9/22/22 - 9/24/22 - 9/25/22 - 9/27/22 - 10/1/22 - 10/2/22 On 10/5/22 at 10:09 AM Staff 1 (Administrator) confirmed the identified dates with no RN coverage.

• No harm, potential for more than minimal, patternF812May 11, 2026

  Based on observation and interview it was determined the facility failed to store food in a sanitary manner for 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illnesses. Findings include:On 5/4/26 at 9:34 AM, a brief kitchen tour was completed and revealed the following:-An opened bag of cereal in dry storage was unlabeled and undated.-An opened container of ranch dressing in the refrigerator was undated.-An open bag containing eight boiled eggs in the refrigerator was unlabeled and undated.-An open block of cheese in the refrigerator was loosely wrapped and undated.On 5/4/26 at 9:36 AM, Staff 13 (Cook) stated staff were to date food products when opened and add a use-by date. […]

• No harm, potential for more than minimal, patternF880May 11, 2026

  Based on observation, interview and record review it was determined the facility failed to implement measures to prevent the spread of infection related to catheter positioning, hand hygiene, and Enhanced Barrier Precautions for 1 of 1 staff member (Staff 8) reviewed during a random observation and 3 of 11 sampled residents (#s 4, 8, and 29) reviewed for infection control. This placed residents at risk for infections. Findings include: 1. On 5/4/26 at 1:32 PM, Resident 4's catheter was observed to be attached to her/his bed with part of the catheter resting on the floor. On 5/6/26 at 11:59 AM Resident 4 was observed with part of the catheter attached to the bed and part of it rested on the floor. […]