Tishomingo Comm Living Center

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 4th Quarter 2025. Findings Include:Record review of the facility policy titled, Staffing Hours-Monitoring of Policy and Procedure undated, revealed, Purpose: To assure the facility staffing meet federal and state guidelines. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2025 (July 1-September 30), revealed the facility triggered on this report for excessively low weekend staffing.During an interview on 12/17/2025 at 3:20 PM, the Administrator revealed that after auditing the low weekend staffing data, she discovered that the data submitted to PBJ was inaccurate. She revealed that both she and the Director of Nurses (DON) had worked some weekends, and their salary hours were not accurately converted to hourly. The Administrator also revealed that, after further investigation into the excessively low weekend staffing, it was discovered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to provide written notification to the resident/representative regarding bed hold when the resident was sent to the hospital for two (2) of two residents reviewed for hospitalization. Resident #1 and Resident #65Findings Include: Review of the facility policy titled, Bed hold Policy and Procedure revealed Policy: Before the facility transfers a resident to the hospital or allows a resident to go on therapeutic leave, written information should be provided to the resident and family member or legal representative specifying the following information: (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the facility; and (ii) The policies regarding bed-hold periods, which should be consistent .In the case of an emergency transfer, a written notification should be given to the family, surrogate, or representative within 24 hours of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interviews and record review, and the facility policy the facility failed to notify the provider of an increase in blood pressure for one (1) of three (3) residents reviewed for blood pressure monitoring. Resident #55 Findings include: Record review of facility policy titled, Blood Pressure, Measuring dated 8/25/24, revealed, Hypertension is usually defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg). Hypertension should be reported to the physician. Record review of facility policy titled, Notification of Changes in a Resident's Condition or Status, undated, revealed, It is the policy of this facility to inform the resident, consult with his or her physician, and notify, consistent with his/her authority, the resident's representative of changes in the resident's condition and/or status. The policy also revealed, 1. Nursing services shall be responsible for notifying the resident's attending physician when: . b. There is a significant change in the resident's physical, mental,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident and staff interviews and record review, the facility failed to notify the resident's representative in writing and the Ombudsman of the emergency transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization. Resident #22 Findings include: Record review of letter dated 7/31/24 on facility letterhead revealed, The facility does not have a policy that states the Responsible Party and/or Ombudsman must be notified in writing of Emergency Transfers. During an interview on 07/29/24 at 11:55 AM, Resident #22 revealed she had been in the hospital recently but she did not remember the date of this. An interview with the Administrator on 7/30/24 at 2:10 PM, revealed the notification to the Ombudsman was not provided and the written notification to Resident #22's representative was not provided. She stated the Medical Records Nurse was the person responsible for this and failed to send these notifications due to the resident returning within a few hours of leaving facility and her name was accidentally removed from the transfer list. She confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review and the facility policy the facility failed to develop a care plan for a resident with a history of hypertension for one (1) of 19 care plans reviewed. Resident #55 Findings included: Record review of facility policy titled, Care Plans, Comprehensive Person-Centered, dated 11/22, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed, 7. The comprehensive, person-centered care plan . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, . e. reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. An interview with Resident #55 on 7/30/24 at 8:50 AM revealed he had a history of hypertension…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and facility policy review, the facility failed to prevent the possibility of an accident while administering medications for one (1) of four (4) residents observed for medication administration. Resident #34 Findings Include: Review of the facility policy titled, Medication Administration-General Guidelines with a revision date of 8/25/14 revealed under Procedure .#1. Preparation: e. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing . An interview and observation on 07/29/24 at 10:44 AM with Resident #34 revealed that her only problem was a huge pill they give her, and she cannot swallow it. She stated it gets stuck in her throat and she just has to let it dissolve. She revealed she told the nurse this morning, but she told her it would not be much longer, and she would not have to take them anymore. An interview on 7/30/24 at 8:00 AM with Licensed Practical Nurse (LPN) #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, record review and facility policy review the facility failed to ensure that the Dietary Manager (DM) had completed required training for dietary management after one year of full-time employment for four (4) or four (4) survey days observed. Findings include: Record review of the facility policy Dietary Manager with a revision date of June 1, 2000 revealed Policy Statement: It is the policy of this facility that the day-to-day functions of the dietary department be under the supervision of a qualified dietary manager . An interview on 5/17/23 at 2:20 PM, with the DM and the Registered Dietician (RD) revealed that the Dietary Manager had been in that position since 5/2022 and had not completed her DM certification course. The DM revealed that she was hired by another Administrator and when the new Administrator started, they discussed the need for her to get her certification, but nothing was ever done. The RD revealed she comes to the facility two times per month. The DM revealed she had one day of training at a sister facility with the Dietary Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility policy review the facility failed to store food in a manner that meets professional standards as evidenced by unlabeled and undated food in the refrigerator, dry food stored uncovered and resident nourishment refrigerators with resident snacks that were unlabeled or undated for two (2) of four (4) survey days. Findings include: Record review of the facility policy titled, Food Storage with a revision date of 8/18/11 revealed . Procedure .2. All foods or food items not requiring refrigeration shall be stored above the floor, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning, in a ventilated room, not subject to sewage or wastewater backfill or contamination by condensation leakage, rodents, or vermin. All package food, canned foods or food items stored shall be kept clean and dry at all times . 9. All leftover foods are to be stored in covered containers, dated, & labeled. Cooked leftovers are to be used reheating to 180 degrees Fahrenheit. If not used by the third (3rd) day, they are to be discarded.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and facility policy review the facility failed to ensure a resident's Advance Directives were honored as evidenced by the facility did not correctly implement the resident's decision on the correct code status for two (2) of 24 resident's reviewed (Resident # 30 and # 51) and failed to have a copy of the Advanced Directive on the medical record for two (2) of 24 residents reviewed. (Resident # 45 and #58) Findings Include: A review of the facility policy titled, Advance Directives, reviewed 11/2022, revealed, Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .Determining Existence of Advance Directive .2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, and facility policy review the facility failed to respect the dignity of a resident as evidenced by not completely covering the resident's naked body while transporting the resident to the shower for one (1) of 67 resident's observed, Resident #33 Findings Include: Record review of the facility policy titled, Dignity and Respect with no revision date revealed under Procedure .#4 Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. An observation on 05/17/23 at 3:36 PM, revealed Certified Nurse Assistant (CNA) #2 pushing Resident #33 down the hall in a shower chair covered in the front with a white facility blanket and no covering over his bare buttocks, which were visible from the back side of the chair as he was being pushed down the hallway. An interview on 5/17/23 at 3:38 PM, with CNA #2 revealed she did not realize that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and review of the statement regarding the facility's policy, the facility failed to submit a change in status for a Level II PASARR (Pre admission Screening and Resident Review) referral for one (1) of four (4) residents reviewed. Resident # 46. Findings Include: Record review of facility policy titled, admission Criteria, dated 4/25/23, revealed, Our facility admits only residents who's medical and nursing care needs can be met. The policy also revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Record review of the signed Administrator's note on facility letterhead dated 5/17/23 revealed, (Proper name of facility) follows state regulations regarding Pre-admission Screening and Resident Review Level II submissions and resubmissions. The facility does not have a separate policy. An interview with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and policy review the facility failed to develop a care plan for cardio-pulmonary resuscitation code status (Resident #30 and Resident #51) and implement a care plan by failing to change a humidifier bottle and tubing, and ensuring a resident received humidified oxygen (Resident # 17) for three (3) of 24 resident reviewed. Findings include: A review of the facility policy titled, Care Plan-Comprehensive, revealed Policy Statement: It is the policy of the facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs . Findings Include: Resident #30 A review of Resident #30's care plan titled, I am A CPR status with a review date of [DATE] revealed, Goals I will receive all measures of comfort care, and life sustaining treatment through each review during nursing home stay. A review of the Advance Health Care Directive signed [DATE] by Resident #30 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review and facility policy review the facility failed to change an oxygen (O2) humidifier bottle and tubing weekly as ordered for one (1) of four (4) residents reviewed for oxygen therapy. Resident #17 Findings include: Record review of the facility policy titled, Oxygen Education, with a date of September 12, 2013, revealed . Important facts: All tubing is changed once a week and clearly marked with the days date . Record review of the facility policy titled, Oxygen Administration, with a Procedure revised date of August 25, 2014, revealed . Steps in the Procedure . 9 . Be sure there is water in the humidifying jar (if used) and that the water level is high enough that the water bubbles as oxygen flows through .11. Periodically re-check the water level in the humidifying jar . An observation of Resident #17 on 5/15/23 at 11:00 AM, revealed the O2 humidifier bottle dated 4/18/23 with no date on tubing connected to the humidifier. An observation of Resident #17 on 5/16/23 at 2:08 PM, revealed an empty O2 humidifier bottle with date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.