Independence Rehab and Nursing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 11, 2026

  Based 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). Findings include: Review of the facility's policy, Accident & Injury Prevention and Response Policy dated January 1, 2026, indicated that the purpose of the policy was to ensure that all residents of the facility are protected from avoidable accidents and injuries through proactive assessment, environmental safety, staff training, and timely response. […]

• Immediate jeopardy, isolatedF689May 2, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Jan 18, 2024

  Based on a review of clinical records, review of facility policies, observations, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect related to Resident R1 not receiving 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 two worsening of wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. […]

• Immediate jeopardy, isolatedF686Jan 18, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 23, 2023

  Based 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). […]