Inspection·April 18, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based 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). Residents Affected - Few 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. Further interview with Resident R1 revealed poor sleep during the days Trazodone was not provided. Continued interview on April 18, 2024, at 12:27 p.m. with Resident R1 revealed the physician did not inform the resident of the medication changes or review alternative treatment options to help him sleep. Review of Resident R1's physician orders revealed the resident was prescribed Trazodone 150 milligrams (mg) at bedtime for insomnia (the inability to sleep adequately) started 2/20/2024 and discontinued 04/08/2024. Review of the discontinued ordered revealed it was marked as completed by the physician. There was no documented evidence by the physician why the medication was completed. Review of Resident R1's medication administration record confirmed the resident did not receive Trazodone on April 8, April 9, and April 10, 2024. Continued review of Resident R1's physician orders revealed the Trazodone 150mg every night was re-started for insomnia on April 11, 2024. Review of Resident R1's entire clinical record revealed no documented evidence that Resident R1 was informed by the physician of the medication change, was allowed to participate in decisions regarding his care and treatment, or that the physician reviewed alternative treatment options to help him sleep. 28 Pa Code 201.18(b)(2) Management (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395330 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395330 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Independence Rehab and Nursing 600 W Cheltenham Avenue Philadelphia, PA 19126 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)