Indianola Rehabilitation And Healthcare Center

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for a resident with known exit-seeking behaviors, resulting in the resident leaving the building and remaining outside unsupervised in cold weather. The resident had a diagnosis that included unspecified dementia and was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 3. Earlier assessments identified the resident as high risk for wandering on 6/24/25, low risk on 11/7/25, and again high risk on 12/31/25. A wander bracelet ordered in June 2025 for dementia and exit-seeking behaviors was discontinued on 10/28/25. On 12/8/25, a Social Services Progress Note documented that the resident was agitated, sitting in the lobby doorway, yelling that he wanted to go home, tapping on the door, and requiring redirection by nursing staff. The Social Worker later confirmed that these were exit-seeking behaviors and acknowledged that additional interventions such as increased monitoring and a wandering assessment should have been implemented but were not. On 12/30/25, staff documented in the Plan of Care Response History at 11:18 AM that the resident exhibited behavioral symptoms of wandering, noted that these behaviors had occurred previously, and documented that the nurse was notified. Multiple staff interviews confirmed that the resident was known to be exit-seeking on a daily basis and required frequent redirection, yet several CNAs and an LPN assumed the resident already had a wander guard in place when he did not. That evening, the resident was last observed by his assigned CNA watching television in the lobby a little after 7:00 PM. At approximately 7:28 PM, the resident exited the facility through the smokers’ courtyard door. The door was later found by the Maintenance Director to have a malfunction in which sustained pressure on the handle allowed it to open without sounding an alarm. Staff near the courtyard, including a CNA who had been in the breakroom by the exit until about 8:30 PM, reported not hearing any alarm and did not observe anything unusual during that time. The resident was eventually discovered outside when a CNA walking down the hall looked through the courtyard door and saw someone sitting on the patio. The CNA obtained another CNA, who identified the individual as the resident. The resident was brought back inside, and staff observed that he was shivering, rubbing his hands together, and that his hands appeared white or pale. The resident later stated he had gone outside at night because he wanted to meet his girlfriend, walked around the yard, and tried to come back in but found the door locked. He reported sitting outside for a long time before someone opened the door and stated he was shaking and very cold when he returned inside. Vital signs, including body temperature, were not obtained until the following morning at 10:50 AM. The incident occurred when outside temperatures were documented as ranging from 32 to 34 degrees Fahrenheit between 8:00 PM and 9:00 PM. The combination of the resident’s known exit-seeking behavior, lack of enhanced monitoring or wandering interventions after documented behaviors, discontinuation and absence of a wander bracelet, staff assumptions about his elopement protections, and a malfunctioning courtyard door that could be opened without an alarm led to the resident’s unsupervised exit and exposure to cold conditions. The situation was determined by the State Agency to constitute Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) at 42 CFR §483.25(d)(1)(2), Free of Accident Hazards/Supervision/Devices (F689), with an IJ level of scope and severity J beginning on 12/8/25, when the resident began exhibiting exit-seeking behaviors. The IJ and SQC were formally communicated to the facility’s Administrator on 1/12/26 at 4:30 PM, and the IJ template was provided. The IJ level was later reduced from J to D after validation that corrective actions in the facility’s removal plan had been completed, while the facility continued to develop and implement a plan of correction and monitor systemic changes for sustained compliance.

Removal Plan

• CNA found Resident #1 unattended on the courtyard patio, brought him back to the facility, and another CNA took him to his room and alerted the charge nurse.
• RN notified the DON that Resident #1 had exited the building and was found in the courtyard.
• DON notified the Administrator; Administrator instructed 1:1 monitoring for the remainder of the night, instructed DON to call Maintenance to check the door, and instructed that a head count of all residents be done immediately.
• DON notified Maintenance to return to the facility and check the door.
• Resident #1 was assessed by nursing with no ill effects.
• DON instructed a CNA to stay with Resident #1 1:1 for the remainder of the night.
• Maintenance checked the door, found it would open if the handle was compressed longer than 10 seconds, adjusted the bolt to disable the feature so the door would not open, and checked all doors and windows.
• Maintenance notified the DON that the door was corrected, room checks had been done, and all residents were accounted for.
• Resident #1 was assessed as a wandering risk and a signaling device was placed on his wrist for monitoring.
• Social Services updated the Residents at Risk for Elopement in the Elopement Binder.
• Elopement drills were started.
• The Administrator reported the incident to the Mississippi State Department of Health and Licensure.
• The Mississippi Attorney General's Office was notified of the incident.
• An Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• The DON conducted an audit of residents at risk for elopement to review wander risk care plans for those residents identified as at risk for wandering.
• In-services began for all staff on elopement, resident rights, proper door functioning, abuse/neglect/reporting, and notifying staff of observed behaviors; staff were not allowed to work until the in-service was completed.
• A revised Ad-Hoc QAPI meeting was held to discuss the incident and findings from the State Surveyor.
• Audit findings for residents at risk for elopement were reviewed with the Administrator, DON, and ADON.
• The Ombudsman was notified.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly resolve resident grievances related to food quality and temperature for five residents who participated in Resident Council meetings. These residents consistently voiced concerns about the poor quality, lack of variety, and improper temperature of meals, including complaints about cold food, overcooked vegetables, repetitive menus, and insufficient fresh fruits and vegetables. Despite these ongoing complaints being discussed in both Resident Council and food committee meetings, there was no evidence that the facility took effective action to address or resolve the issues. Documentation of these grievances was lacking. Resident Council and Food Committee meeting minutes did not record specific resident complaints or detail any actions taken to address the concerns. The Activities Director acknowledged hearing the complaints but did not formally document them, instead relying on the dietary manager to keep notes in a personal notebook. The dietary manager confirmed that grievances were not officially completed, and there was no documentation to show that the residents' concerns were addressed or resolved. Interviews with facility staff, including the Administrator, Dietary Manager, and Regional Dietary Manager, revealed awareness of the food-related complaints but also confirmed the absence of a formal grievance process or paper trail to track the resolution of these issues. All five residents involved were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores, and had repeatedly expressed their dissatisfaction with the food service without seeing meaningful changes or responses from the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A medication cart was observed unlocked and unattended in front of the A Hall nurses' station on two separate occasions during the survey, with no staff present in the vicinity. Facility policy requires that medication carts remain locked and not be left unattended. During an interview, an RN admitted to leaving the cart unlocked and unattended, acknowledging that this was against policy and could allow a resident to access medications. The RN also noted that there was a resident known to wander in the area who could potentially access the cart. The facility administrator confirmed that medication carts must be locked whenever staff step away and recognized the risk associated with leaving the cart unsecured. No specific residents were reported to have accessed the cart or been harmed at the time of the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's call light was within reach, limiting the resident's ability to request assistance as needed over a period of two out of three survey days. Multiple observations showed the call light cord hanging from the wall by the foot of the bed and lying on the floor, making it inaccessible to the resident. The resident reported being unable to reach the call light and stated that staff did not place it within her reach. These observations were consistent across several times and dates, with the call light remaining out of reach for extended periods, including overnight. Staff interviews confirmed that the call light was not accessible and acknowledged that it should have been placed within the resident's reach. The facility's policy requires that call lights be accessible to residents at all times. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including osteoarthritis, anxiety disorder, and convulsions. The deficiency was corroborated by both staff and administrative personnel, who confirmed the expectation that call lights be accessible for resident safety and care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when an oxygen concentrator in use by a resident in room A-21-W was observed to be soiled with multiple dime-sized, light brown dried substances on top and a two-inch streak of a similar substance down the front. The soiling was confirmed to be formula from the resident's tube feeding. Facility policy requires that resident-care equipment, including durable medical equipment, be cleaned and disinfected according to CDC recommendations. During interviews, housekeeping staff stated they do not clean medical equipment currently in use, citing concerns about interfering with device settings, and indicated that the Nursing Department is responsible for cleaning such equipment. Nursing staff verified the soiling and acknowledged that it should have been cleaned to prevent attracting pests. The DON confirmed that it is the expectation for nursing staff to clean the oxygen concentrator if it becomes soiled.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement person-centered care plans for personal hygiene for two residents with significant self-care deficits. For one resident with dementia, confusion, impaired mobility, and contractures, the care plan required staff assistance with activities of daily living (ADLs), including personal hygiene and nail care as needed. Despite this, the resident was observed with long fingernails and a brown substance under every nail bed, and staff interviews confirmed that the care plan was not followed. Documentation showed the resident was dependent for personal hygiene, with no refusals recorded during the review period. Another resident, dependent on staff due to right-side hemiparesis, contracture, and impaired mobility, had a care plan specifying total dependence on staff for bathing and personal hygiene. Observations revealed the resident had unkempt, greasy hair and long, jagged fingernails with a brown substance underneath. Staff interviews confirmed that nail and hair care were not performed as required by the care plan, and that there was no set schedule for nail care. The care plan was acknowledged by staff to include these hygiene tasks, but they were not carried out, resulting in the resident not being kept clean and presentable as intended.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate personal hygiene care for two residents who were dependent on staff for activities of daily living. For one resident with dementia and joint contracture, observations on consecutive days revealed fingernails extending approximately half an inch past the fingertips with a brown substance underneath, and no evidence of nail care or documentation of refusals in the medical record for the previous month. Staff interviews confirmed that the resident did not refuse care and that the facility's expectation was for staff to maintain the resident's nail hygiene. Another resident, diagnosed with cerebral infarction, hemiplegia, hemiparesis, and dementia, was observed on multiple occasions with unkempt, greasy hair and long, jagged fingernails containing a brown substance. The CNA responsible for the resident's care admitted to not washing the resident's hair and only attempting to clean under the fingernails. Both the ADON and DON confirmed that the resident's personal hygiene needs, including nail and hair care, were not met as required by facility policy and staff expectations.

Penalty

Inspection fine: $8,512

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from neglect, resulting in a serious injury that went unreported and untreated for several hours. A Certified Nursing Assistant (CNA) did not report that the resident hit his head during care, leading to a significant right eye injury with fractures to the orbital bones. The incident occurred during the morning shift, but the CNA did not inform anyone about the resident hitting his head, and the Director of Nursing (DON) was not contacted until later in the day. The resident was sent to dialysis with visible injuries, including a swollen shut eye and a bloody nose, without prior assessment or documentation by the facility staff. Interviews with facility staff revealed a lack of communication and documentation regarding the incident. The Licensed Practical Nurse (LPN) on duty during the morning shift was informed of the resident's injuries but did not document the incident or ensure immediate medical evaluation. The DON was notified but did not come to the facility to investigate, resulting in a delay in addressing the resident's injuries. The resident was eventually sent to the emergency room after dialysis, where further evaluation revealed fractures and other injuries. The resident, who was cognitively intact, initially reported that he was involved in a tussle with the CNA, but later stated he might have hit himself. The facility's failure to promptly assess and report the incident, as well as the CNA's decision to continue care without assistance despite the resident's resistance, contributed to the neglect. The incident was reported to local authorities, and an investigation was initiated to determine the circumstances surrounding the resident's injuries.

Penalty

Inspection fine: $8,512

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement the Activities of Daily Living (ADL) care plan for a resident who was known to have inappropriate behaviors and was at risk for injuries and complications. The care plan included interventions such as monitoring behaviors, notifying the charge nurse or supervisor, and redirecting as needed. However, during an incident, a Certified Nursing Assistant (CNA) did not follow these protocols when the resident resisted care. The CNA did not notify the charge nurse or obtain help from additional staff, resulting in the resident sustaining fractures to his orbital bones during an altercation. Interviews with facility staff, including the Director of Nursing (DON), Licensed Practical Nurse (LPN), and the Minimum Data Set (MDS) nurse, confirmed that the CNA did not report the incident or seek assistance when the resident became resistant. The CNA admitted that the resident hit his head on a bedside table during the altercation but did not report it because the resident did not complain of pain. The LPN acknowledged that the CNA should have called for help and documented the incident, while the MDS nurse confirmed that the ADL care plan was not appropriately followed, as staff are trained to leave the room and obtain additional assistance when a resident exhibits behaviors.