Tishomingo Manor

Based on staff interview, record review, and Payroll-Based Journal (PBJ) staffing data review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 1st Quarter, 2025 (October 1 through December 31, 2024) Findings Include: An interview with the Administrator on 4/02/25 at 10:02 AM revealed the facility did not have a policy for submitting Payroll-Based Journal. Record review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for excessively low weekend staffing for the 1st quarter, 2025 (October 1 through December 31, 2024). An interview with the Staff Development Nurse on 4/01/25 at 10:10 AM revealed the facility's staffing needs were based on the minimum hours PPD (per patient day) requirement and by determining the resident acuity for each hall. She revealed call-ins were the biggest concern for weekend staffing. She indicated if a staff member clocked in late for their shift, that would affect the PPD. The Staff Development Nurse indicated they had…

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 ensure the dignity of one (1) of four (4) residents observed during medication administration. Resident #12. Findings Include: Review of the facility policy titled Dignity and Respect with a revision date of 7/2022 revealed, 5. Residents will be examined and treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care. On 4/01/25 at 8:48 AM, an observation of Licensed Practical Nurse (LPN) #1 revealed, she administered Resident #12's, who was a female resident, Percutaneous Endoscopic Gastrostomy (PEG) tube medications without closing the resident's room door, blinds, or pulling the privacy curtain. The door of the resident's room remained open and anyone passing in the hallway could see that the resident's abdomen area was exposed. An interview with LPN #1 on 4/01/25 at 9:10 AM, confirmed she did not ensure the resident had privacy while administering medications…

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 record review, staff interview and facility policy review the facility failed to implement care plan interventions for a resident on a fluid restriction for one (1) of 24 care plans reviewed. Resident # 25. Findings Included: Record review of the facility policy Care Plan Process , revised 12/2024, revealed The overall care plan should be oriented towards .2. Managing risk factors to the extent possible .Interventions are actions that should promote meeting the established goal. A record review of the Care Plan Report for Resident #25 revealed, under Focus, Potential fluid volume overload related to Kidney failure. Under Interventions/Tasks it revealed 2,000-milliliter (ml) fluid restriction, with 120 ml allocated for four (4) medication passes, totaling 480 ml, and 500 ml with meals, totaling 1,500 ml, with a created date of 1/27/25. A record review of the electronic Medication Administration Record (MAR) for Resident #25 revealed no documentation of the resident's fluid intake. On 4/1/25 at 1:00 PM, during an interview Licensed Practical Nurse (LPN) #3 confirmed 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.

Based on record reviews, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of three (3) residents reviewed for hydration. Resident #25. Findings Include: A record review of the facility policy Physician Orders, revised 1/2025, revealed, It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. A record review of the facility policy Fluid Restriction, revised 2/2022, revealed, Fluids will be restricted for residents as directed by physician orders . Nursing services will document intake and output. A record review of physician orders revealed that Resident #25 was placed on a 2,000-milliliter (ml) fluid restriction, with 120 ml allocated for four (4) medication passes, totaling 480 ml, and 500 ml with meals, totaling 1,500 ml. This order was initiated on 1/30/25. A record review of the electronic Medication Administration Record (MAR) for Resident #25 revealed no documentation of the resident's fluid intake. During an interview on…

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 follow Enhanced Barrier Precautions (EBP) for one (1) of three (3) resident care observations. Resident #12. Findings Include: Review of the facility policy titled Enhanced Barrier Precautions with a revision date of 3/2024 revealed, Enhanced Barrier Precautions are indicated for residents with any of the following: . Wounds and/or indwelling medical devices . An observation outside Resident #12's room door on 4/1/25 at 8:42 AM, revealed a sign that read, Enhanced Barrier Precautions. On 4/01/25 at 9:01 AM, an observation during medication administration with Licensed Practical Nurse (LPN) #1 revealed, she administered medications to Resident #12 via (by) Percutaneous Endoscopic Gastrostomy (PEG) tube without using a gown for EBP. An interview on 4/01/25 at 9:11 AM, with LPN #1, confirmed she did not apply a gown to administer Resident #12's medications. She explained that the gowns were not hanging on the resident's door; therefore, she did not realize she was supposed to wear one. 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 and record review the facility failed to submit accurate data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. First quarter 2024. Findings include: Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2024 (October 1-December 31), revealed Excessively Low Weekend Staffing-Triggered. Triggered=Submitted Weekend Staffing data is excessively low. During an interview on 5/21/24 at 9:53 AM, the Administrator (ADM) revealed the PBJ data is based on the hours entered in the time clock and goes directly to the corporate office. She revealed the agency staff that we utilize is manually entered into the system along with nursing administrative staff who occasionally work on the weekends doing patient care. The Administrator confirmed the hours worked by the nursing administrative staff were not captured correctly on the PBJ and were done so in error. She revealed the shifts for the first quarter of 2024 were covered, however, the data was entered incorrectly and did not capture the direct care…

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 maintain a medication administration error rate by less than 5% for four (4) of 25 medication administration opportunities. The medication error rate was 16%. Findings Include: Record review of the facility titled, Administration of Medications, dated 01/24, revealed, PURPOSE: To administer medications in accordance with best practice .ORAL MEDICATION ADMINISTRATION PROCEDURE . 7. If resident requires crushed medications Do not crush time release or enteric coated medications. Consult pharmacist for direction with questions . During a medication administration observation on 5/21/24 at 8:15 AM, with Licensed Practical Nurse (LPN) #1 on the C-Hall revealed the following: LPN #1 gathered medications for Resident #81 that included Coreg 12.5 mg (milligrams) (1) tablet, Potassium 20 meq (milliequivalents) CL (Chloride) ER (Extended Release) (1) tablet, Loratadine 10 mg (1) tablet and Citracel plus Vitamin D Maximum 250 units (1) tablet and placed the medications all in a bag and…

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 interviews, record review and facility policy review, the facility failed to provide dignity to residents as evidenced by leaving urinary catheter bags uncovered for one (1) of nine (9) residents with a catheter, Resident #244. Facility failed to serve meals trays concurrently at a table of three (3) residents in the dining room for two (2) of four (4) meals observed for Resident #20, #39, and #295. Findings include: Review of the facility policy titled, Dignity and Respect, with the latest revision date of 7/22 revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. Review of the facility policy titled, Resident Tray Service and Delivery, with the latest revision date of 5/18, revealed, #6. Meal tray delivery-dining room . j. Trays are served concurrently to all residents seated at…

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 interviews, record review, and facility policy review, the facility failed to report an incident of resident-on-resident abuse timely for one (1) of 21 residents sampled. Resident #65 Findings include: Record review of facility policy titled, Incident Investigation and Reporting, dated 10/22, revealed, Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to (proper name of stage agency), Attorney General, local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes .3 The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than two (2) hours after forming 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 observation, staff interviews, record review, and facility policy review the facility failed to ensure a resident with an indwelling catheter received the appropriate care and services to prevent Urinary Tract Infections (UTIs) to the extent possible for one (1) of nine (9) residents observed with an indwelling catheter. Resident #244 Findings include: Record review of the facility policy titled, Urinary Catheter with a revision date of 10/21 revealed, . 24. Secure indwelling catheter with catheter strap or other securement device. b. Male i. Secure catheter tubing to upper thigh or lower abdomen. During an observation and interview with Licensed Practical Nurse (LPN) #1 on 05/21/23 at 6:05 PM, she confirmed that Resident #244 did not have a leg strap on to properly secure the catheter tubing and revealed it could cause a pull to his catheter and cause him problems, such as dislodgement or bladder spasms. An observation and interview on 05/21/23 at 6:20 PM, the Director of Nurses (DON) confirmed every…

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.