Health inspection·May 2, 2024

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few he can have a shower. Employee E7 continued her statement and reported, He's always nice, polite, and easily directed, and paces the floor. I didn't bother him that night because I figured since I didn't see him like I usually do on the unit, then he is finally sleep for once, so I'll just let him sleep. Review of the resident's Medication Administration Record (MAR) and the resident's Treatment Administration Record (TAR) for the month of April indicated that although it was determined through the investigation that Resident R1 was not in the building during the 11:00 p.m. through the 7:00 a.m. nursing shift, in addition to Employee E7 statement about not seeing the resident at anytime during her shift, Employee E7 documented on the MAR/TAR that during her shift on April 22, 2004 she provided the resident with treatment and services, as outlined in his physician orders, which included, checking placement of the resident's pressure reducing mattress in his bedroom; checking the placement, function of the wanderguard, in addition to checking the resident's skin integrity on the area and surrounding area where the resident wears the wanderguard. Other treatment and services that Employee E7 documented on the MAR/TAR on April 22, 20024 during her shift as being provided included assessing the resident for pain every shift, and documenting that the resident exhibited no pain, by marking 0, in addition to documenting that Resident R1 was not exhibiting any signs of respiratory infections and documenting his temperature as 97.7 and his oxygen saturation as 97. Review of the MAR/TAR also revealed that Employee E7 documented that she administered barrier cream to the resident during her 11:00 p.m. through 7:00 a.m. nursing shift, in addition to documenting that she provided Resident R1 with 120 cubic centimeters (4 ounces) of fluids on her shift during his medication pass. Review of the resident's April 2024 physician orders did not show evidence that Resident R1 was ordered to have any medication administered to him on that shift. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) April 30, 2024 at 2:34 p.m. Discussed that Employee E7 documented on the MAR/TAR that she provided treatment and services to the resident, despite Resident R1 not being present in the building, and Employee E7 stating that she did not see him at all during her shift. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 2 of 11 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 05/02/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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. (Resident R1) Findings include: Review of the facility policy, Elopements and Wandering Residents, with a revision date of April 23, 2024, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Continued review of the policy indicated that residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The policy also indicated that adequate supervision will be provided to help prevent accidents or elopements. Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior). Review of an admission note dated March 27, 2024, at 6:37 p.m. written by Employee E3 (licensed nurse) indicated that the resident was admitted to the facility on the above referenced date from the local hospital after suffering a heart attack. Continued review of the above referenced admission note indicated resident is at risk of elopement, wandering or exit seeking behaviors. Review of the resident's discharge hospital records dated March 27, 2024, indicated that the resident did not have the capacity to make his medical decisions. Review of a court order dated March 19, 2024 stated that the resident was adjudicated on the above referenced date as a totally incapacitated person, and had an appointed Guardian (someone appointed by the court to manage the personal and financial affairs an individual who the court has determined lacks the capacity to make his/her own decisions). Review of the resident's Elopement Assessment dated March 27, 2024, indicated that the resident was at risk for elopement. The assessment indicated that resident Expresses desire to leave, Independently mobile, Adjustment difficulties, Desire to return home, in addition to a Psychiatric history. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 3 of 11 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 05/02/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of Resident R1's March 2024 physician orders indicated a physician order dated March 28, 2024, and monthly thereafter, for the resident to have a wanderguard (an electronic device that is typically applied on an individual's ankle or wrist to alert his/her caregivers (with an alarm) when that individual is near an exit location (e.g. doors, elevators) applied to his left ankle. The order also indicated that on every nursing shift, staff is to ensure to check the placement and function of the wanderguard. Continued review of the March 28, 2024, physician orders also included a physician's order for the 11:00 p.m. -7:00 a.m. supervisor to check the function of the resident's wanderguard during his/her shift. Review of the resident's person-centered plan of care included a plan of care dated March 28, 2024, that indicated that the resident was at risk for injury related to elopement and wandering. The resident expressed intent to leave facility. The plan of care also included the resident's diagnosis of Schizophrenia. The interventions related to this care area included involving the resident in activities, reporting changes in behavior, provide activities of interest, in addition to the application of a wanderguard. Review of a nursing note dated March 28, 2024, at 6:17 a.m. indicated .wander guard placed to left ankle due to reports of wandering. Review of a nursing note on March 28, 2024, at 1:10 p.m. documented that the resident was at the nursing station asking, how do I get out of here? Review of a nursing note dated March 30, 2024, at 6:46 p.m. revealed Resident came to the nursing office asking if I could give him a day pass to go to 7-11 mini market. Resident is an elopement risk, but no attempts to leave out of the facility. Resident does have wanderguard applied to his left ankle. Plan of care is ongoing. Review of a nursing note on April 5, 2024, at 6:56 a.m. indicated that the resident was not wearing his wanderguard and that another one was placed on his ankle. Review of a nursing note dated April 11, 2024, at 5:06 p.m. indicated that the resident's wanderguard bracelet was found in his bedside drawer, and that the resident stated that he did not want to wear it. Continued review of the note indicated that the resident did not want the wanderguard on his ankle so nursing staff applied the wanderguard to his left wrist. Review of a nursing note dated April 12, 2024, at 2:37 a.m. the resident was found with the wanderguard bracelet inside the dresser next to his bed. The note documented that the resident reported that he did not want the wanderguard on him. Review of a nursing note dated April 13, 2024, at 3:10 p.m. documented Resident is alert and oriented x 3 Confusion noted. Exhibits anxiety, wanders Review of a nursing note on April 14, 2024, at 5:19 p.m. documented that the resident is an elopement risk and that he continues to remove his wanderguard. Review of a nursing note dated April 14, 2024, at 2:15 p.m. indicated that the resident was pacing back and forth throughout shift and needed to be redirected. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 4 of 11 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 05/02/2024 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)

F 0689 Review of a nursing note dated April 15, 2024, indicated . resident continues refusing wanderguard. Level of Harm - Immediate jeopardy to resident health or safety Review of a nursing note dated April 18, 2024, at 11:58 a.m. indicated that resident informed the social services director that he wanted to discharge home to his apartment. Residents Affected - Few Review of a nursing not dated April 18, 2024, at 2:59 p.m. documented Resident received at front desk. Resident was assisted back upstairs by charge nurse. Review of information submitted to the State Survey Agency on April 24, 2024, indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement. Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024, 8:42 p.m. on the third floor walking to his room. A summary of interviews conducted with facility staff (licensed nurses and nursing assistants) who worked on the 3:00 p.m. through 11:00 p.m. shift that the resident was last seen on, indicated that the general time period that staff reported last seeing the resident on the third floor where his room was located between 8:00 p.m. through 9:00 p.m. Review of a statement from Employee E4 (licensed nurse assigned to Resident R1) dated April 23, 2024, reported that she last saw Resident R1 out of bed walking in the hallway around 9:00 p.m. on April 22, 2024. Employee E4 reported that she administered the resident his medication at approximately 8:30 p.m., asked him if he was ok, and reported that the resident nodded yes. Review of an interview conducted by the facility dated April 23, 2024, with the nurse aide, Employee E5 assigned to the resident on April 22, 2024 during the 3:00 p.m. through the 11:00 p.m. nursing shift indicated that she saw Resident R1 between 8:00 p.m. and 9:00 p.m. in his room. During an interview with Employee E5 on April 30, 2024 at 12:18 p.m. the employee confirmed the statement provided to the facility. Employee E5 reported that she went in to check on the resident during the above referenced time to see if he needed anything (e.g. wash towels, socks). Employee E5 reported that Resident R1 told her that he did not need anything. Employee E5 reported that the resident was sitting on the edge of his bed during her encounter with him. Review of an interview conducted by the facility dated April 23, 2024 with the nurse aide, Employee E6 assigned to Resident R1 on April 22, 2024 during the 11:00 p.m. through the 7:00 a.m. shift stated, I really didn't see [Resident R1] on 11-7 shift because I know he walks around the building. I know he usually does his own thing. During an interview on April 30, 2024 at 1:28 p.m. via telephone with Employee E6, confirmed that he was assigned to Resident R1 on the above referenced shift, and reported that he did not see the resident that he was assigned to at all during his 8 hour shift. Review of the investigation did not show evidence of the facility conducting an interview yet with Employee E7 (licensed nurse), who was assigned to Resident R1 on April 22, 2024, on the 11:00 p.m. through the 7:00 p.m. nursing shift. During a telephone interview with Employee E7 (licensed nurse) on April 30, 2024 at 1:32 p.m. Employee E7 confirmed that she was assigned to the resident on the above referenced shift. Employee E7 also reported that she did not remember seeing the resident at all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 5 of 11 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 05/02/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few during her shift. She stated, that the resident was always out. I work on the floor 3-4 times a week, so I always see him out in the hallway asking if he can get on the elevator or asking if he can have a shower. Employee E7 continued her statement and reported, He's always nice, polite, and easily directed, and paces the floor. I didn't bother him that night because I figured since I didn't see him like I usually do on the unit, then he is finally sleep for once, so I'll just let him sleep. Review of an interview conducted by the facility dated April 23, 2024, with nurse aide (Employee E8) who was assigned to Resident R1 on April 23, 2024 from 7:00 a.m. through 3:00 p.m. reported that she saw the resident at approximately 8:17 a.m. She reported that he was dressed and heading to the elevator. During an interview with the state surveyor on April 30, 2024, at 12:28 p.m. Employee E8 reported that she thought she saw the resident get on the elevator at 8:17 a.m. in the morning. Employee E8 also stated that she placed the resident's breakfast tray in his room and that the resident was not present at the time that she delivered the breakfast tray to him. Employee E8 reported that she came back around 12:00 p.m. and noticed that he did not eat it. Employee E8 reported that she contacted the unit manager to let her know that he did not eat his breakfast and that the name Dr. Walker was called throughout the facility, which is a code word used to notify staff that there was a resident whose presence in the facility cannot be accounted for. Review of an interview conducted by the facility with Resident R2 (Resident R1's roommate) on April 24, 2024, revealed that Resident R2 notified the facility that he did notice that the window was open because he felt a breeze. Resident R2 stated that when he felt the breeze he walked over to the window and noticed that the window was pulled out of its frame and was lying on the floor. Resident R2 stated that he picked the window up, and put the window back in the frame. During an interview with Resident R2 on April 30, 2024 at 10:27 a.m. Resident R2 reiterated his account of seeing the window on the floor, picking it up and inserting it back into the window frame. Review of an interview conducted by the facility dated April 23, 2024, with licensed nurse (Employee E9) assigned to Resident R1 on April 23, 2024, from 7:00 a.m. through 3:00 p.m. indicated that the employee stated that she attempted to provide the resident with his medications in the morning but was told by staff that the resident wanders in the building, and that it was his baseline behavior. Employee E9 reported that she looked for the resident in his room while administering medication to other residents, but she still did not see the resident. Review of the investigation indicated that when it was noted that the resident had not eaten his breakfast, and not had his medication administered to him, the Unit Manager was notified, and the facility initiated their elopement protocol to locate Resident R1. Review of an account from the Social Services Director (SSD, Employee E10) dated April 23, 2024 at 1:00 p.m. the SSD that both he and Employee E11 (Social services assistant) drove to the resident's old apartment, called the resident Guardian to see if she had working cell phone number for him. The Social services director reported that he was able to make contact with the resident at approximately 1:30 p.m. when the resident told the SSD that he was in the hospital because he climbed out of his window the previous evening an attempt to go home. Continued review of the investigation completed by the facility indicated that when the resident exited out of his third-floor window, he sustained injuries that caused him to call 911 (Emergency Medical services) for transportation to the hospital. During an interview with Resident R1 on May 2, 2024, at 9:15 a.m. Resident R1 reported that he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 6 of 11 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 05/02/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wanted to leave the facility, so he jumped out of a window. Resident R1 reported that he lifted the window out of its frame. When asked if he used any tools (knife, pen, etc), Resident R1 stated, I only used my hands. I was surprised it came out that easy. Resident R1 reported that he moved a short distance of where he landed when he jumped and called 911 to pick him up because he could not walk. Review of the resident's History and Physical report dated April 23, 2024 at 3:39 p.m. indicated that the resident fractured both his right and left legs. Continued review of the report indicated that the resident also had a fracture of the third lumbar spine vertebra (L3). Review of the resident's clinical record and the facility investigation did not show evidence of any supervision or monitoring that were put in place for Resident R1 who was identified as an elopement risk upon admission and refused to wear his wanderguard. Resident R1 was last seen entering his room at 8:42 p.m. on April 22, 2024, and not noticed missing from the building until April 23, 2024, at approximately 12:00 p.m. 15 hours later. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing on April 30, 2024, at 12:45 p.m. the facility determined that Resident R1 exited the facility through his window that the room rounds, and bed checks were not completed properly by nursing staff. The facility failed to adequately supervise a resident who was at risk for elopement and failed to secure windows on the unit. This failure to adequately supervise a resident at risk for elopement resulted in the resident exiting the building by jumping from his 3rd floor bedroom window and sustaining serious injuries resulting in an immediate jeopardy situation. Based on the above findings an Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on April 30, 2024, at 2:34 p.m., for failure to adequately supervise a resident at risk for elopement, and failure to secure windows on the unit. The Immediate Jeopardy template was provided to the Administrator and an immediate action plan was requested. On April 30, 2024, at 8:59 p.m. the facility provided the following corrective action plan: 1. On April 23, 2024, an audit of all resident room windows were completed by the maintenance director. The maintenance director installed an additional bracket to all resident rooms to prevent the windows from being removed from the frame. 2. On April 23, 2024, the DON (Director of Nursing)/designee reviewed all resident care plans and reviewed and revised them to reflect elopement risk assessment findings. 3. On April 23, 2024, the DON/designee(s)re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool. 4. DON, designee(s) will complete elopement risk assessments that will assess residents on admission, quarterly, and in the event of a significant change. 5. On April 23, 2024, the DON/designee also in-serviced nurse aide staff on completing checks on the residents that they are assigned to every two hours during their shift to account for the resident's whereabouts. Licensed nurses were also serviced to ensure that head counts of residents are completed on their nursing shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 7 of 11 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 05/02/2024 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Interviews were conducted with facility staff on May 1, 2024, between 1:30 p.m.- 3:35 p.m. to verify the implementation of the action plan. Facility staff was able to verbalize what they would do if they found a resident with exit seeking behaviors, and the proper procedure for alerting management. Review was conducted of the education provided to facility staff related to resident elopement and the Immediate Jeopardy was lifted on May 1, 2024, at 4:16 p.m. Residents Affected - Few 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)Management 28 Pa. Code 201.18 (b)(3)Management 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 8 of 11 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 05/02/2024 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)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based 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) Residents Affected - Some Findings include: Review of the job description for the Nursing Home Administrator (NHA) stated, The Administator is responsible for planning and is accountable for all activities and departments of the center subject to rules and regulations promulgated by government agencies to ensure proper healthcare services to residents. The Administrator administers, directs and coordinates all activities of the center to assure that the highest degree of quality of care is consistently provided to the residents of the facility. Review of the job description for the Director of Nursing (DON) stated, The Director of Nursing is responsible for administration of nursing service in the nursing center. He/she directs, plan and coordinates service activities of professional nursing and auxiliary nursing personnel in rendering resident care. The Director of Nursing interprets center policies and regulation to all nursing personnel and ensures compliance, as well as analyzes and evaluates nursing and related service rendered to improve quality of resident care and to better utilize staff time and abilities. The Director of Nursing also ensures the provision of in-service training programs for nursing personnel. Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior). Review of an admission note dated March 27, 2024, at 6:37 p.m. written by Employee E3 (licensed nurse) indicated that the resident was admitted to the facility on the above referenced date from the local hospital after suffering a heart attack. Review of the resident's person-centered plan of care included a plan of care dated March 28, 2024, that indicated that the resident was at risk for injury related to elopement and wandering. Review of information submitted to the State Survey Agency on April 24, 2024, indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement. Review of a timeline of the investigation indicated that the resident was last observed by the facility's surveillance cameras on April 22, 2024, 8:42 p.m. on the third floor walking to his room. Review of an interview conducted by the facility dated April 23, 2024, with nurse aide (Employee E8) who was assigned to Resident R1 on April 23, 2024 from 7:00 a.m. through 3:00 p.m. reported that she saw the resident at approximately 8:17 a.m. She reported that he was dressed and heading to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 9 of 11 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 05/02/2024 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)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some elevator. During an interview with the state surveyor on April 30, 2024, at 12:28 p.m. Employee E8 reported that she thought she saw the resident get on the elevator at 8:17 a.m. in the morning. Employee E8 also stated that she placed the resident's breakfast tray in his room and that the resident was not present at the time that she delivered the breakfast tray to him. Employee E8 reported that she came back around 12:00 p.m. and noticed that he did not eat it. Employee E8 reported that she contacted the unit manager to let her know that he did not eat his breakfast and that the name Dr. Walker was called throughout the facility, which is a code word used to notify staff that there was a resident whose presence in the facility cannot be accounted for. Review of an interview conducted by the facility with Resident R2 (Resident R1's roommate) on April 24, 2024, revealed that Resident R2 notified the facility that he did notice that the window was open because he felt a breeze. Resident R2 stated that when he felt the breeze he walked over to the window and noticed that the window was pulled out of its frame and was lying on the floor. Resident R2 stated that he picked the window up, and put the window back in the frame. During an interview with Resident R2 on April 30, 2024 at 10:27 a.m. Resident R2 reiterated his account of seeing the window on the floor, picking it up and inserting it back into the window frame. Review of an account from the Social Services Director (SSD, Employee E10) dated April 23, 2024 at 1:00 p.m. the SSD that both he and Employee E11 (Social services assistant) drove to the resident's old apartment, called the resident Guardian to see if she had working cell phone number for him. The Social services director reported that he was able to make contact with the resident at approximately 1:30 p.m. when the resident told the SSD that he was in the hospital because he climbed out of his window the previous evening an attempt to go home. Continued review of the investigation completed by the facility revealed that Resident R1 was last seen entering his bedroom at 8:42 p.m. on April 22, 2024 on facility surveillance footage, however nursing staff assigned to Resident R1 did not noticed that the resident was missing from the facility until the next day, April 23, 2024 at approximately 12:00 p.m. 15 hours after the resident was last seen entering his room. Based on the deficiencies identified in this report, the NHA and DON failed to fulfill essential duties and responsibilities of their position, contributing to the Immediate Jeopardy situation. Refer to F689. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.18(e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 10 of 11 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 05/02/2024 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based 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). Findings include: Review of the facility policy, Documentation in Medical Record dated April 23, 2024 indicated that resident medical records shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Review of the April 2024 physician orders for Resident R1 included the diagnoses of St- Elevation myocardial infarction (a type of heart attack that affects the lower chambers of the heart); heart failure (when the heart muscle doesn't pump blood as well as it should) encephalopathy (a general term describing a disease that affects the function or structure of an individual's brain), and schizophrenia (a mental disorder characterized by false beliefs that conflict with reality, in addition to seeing, hearing, feeling or smelling something that does not exist, disorganized thoughts, speech and behavior). Review of an incident reported to the State Survey Agency on April 24, 2024 indicated that the resident eloped from the facility and was currently in the hospital with injuries sustained during the elopement, which included two broken legs, when the resident jumped out of his third floor window Review of the resident's clinical record revealed no documentation related to the resident's elopement incident, his current hospitalization, injuries, and any documentation in the clinical record that the facility provided notification to the resident's court-appointed Guardian about the incident. 28 Pa. Code 211.5 (f)(ii) Medical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395330 If continuation sheet Page 11 of 11