Tippah County Nursing Home

Inspectors wroteBased on review of personnel records and staff interviews, the facility failed to ensure that the Dietary Manager was qualified by obtaining or enrolling in a Certified Dietary Manager (CDM) program for three (3) of 3 days of survey. Review of facility policies related to dietary staff qualifications was requested. Facility staff were unable to provide a policy outlining requirements for Certified Dietary Manager (CDM) certification. During an interview on 2/18/26 at 10:55 AM, the Dietary Manager stated he had not completed a Certified Dietary Manager (CDM) program, and he was unaware that he was required to obtain certification. Record review of personnel records revealed the Dietary Manager was hired approximately two years ago and has not completed or enrolled in a CDM program. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to implement infection prevention and control practices to prevent the transmission of infections. Specifically, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during catheter care and failed to perform hand hygiene during wound care for two (2) of three (3) resident care opportunities. (Residents #3 and #6)

Inspectors wroteBased on staff and family interview, facility policy review and record review, the facility failed to act on and resolve grievances related to maintaining Activity of Daily Living (ADL) needs for incontinent residents for one (1) of three (3) family interviews conducted. Resident #27 Findings Include: Review of the facility policy titled Activities of Daily Living (ADL) Care, dated 04/09/2018, stated, To ensure all ADL care is provided on a daily basis as needed to ensure that all the residents' needs are met. On each shift all residents are checked every two hours, and adult brief is changed if needed. An interview conducted via telephone with Resident #27's caregiver on 2/18/26 at 8:53 AM, revealed the caregiver reported Resident #27 had been left in a soiled brief on more than one occasion while she was visiting daily. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a safe, clean, and homelike environment by ensuring window coverings were intact and in good repair for two (2) of the twenty-nine resident rooms observed. (room [ROOM NUMBER] and #232). Findings Include:Record review of the facility policy titled, Homelike Environment dated 11/21/2024, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment. During the initial tour on 2/17/26 between 10:37 AM and 10:43 AM, observation revealed the window blinds in rooms 230 and room [ROOM NUMBER] had broken and missing slats, leaving an approximate 30-inch gap at the bottom and exposing the outside elements. [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to implement comprehensive care plans for one (1) of 13 sampled residents. (Resident #2)

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of 13 sampled residents. (Resident #2).

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for one (1) of three (3) residents observed during medication pass (Resident #38) Findings Include:Review of facility policy titled, Medication Administration with revision date 6/7/2016, revealed, .Procedures.5. If there is a discrepancy between the Emar and the label, check physician/NP (nurse practitioner) orders before administering the medication. 6. If label is wrong, call resident's personal pharmacy for a new label. If the Emar is wrong, correct the order in the computer system. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for residents' use as evidenced by both facility's shower rooms being in disrepair for two (2) entrance areas of two (2) shower rooms in the facility.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to develop a care plan for hospice service for one (1) of 14 sampled residents' care plans reviewed.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the proper storage of a nebulizer facial mask and tubing to prevent contamination and the possibility of infection for one (1) of fourteen sampled residents. Resident #21. Findings Include: Record review of the facility policy titled Oxygen/Nebulizer and Continuous Positive Airway Pressure (CPAP) Supplies with a revision date of 03/13/18 revealed .Place Oxygen/Nebulizer tubing/supplies and CPAP mask/supplies in plastic bag after each use An observation on 11/04/24 at 10:40 AM, revealed a nebulizer machine on the nightstand next to Resident #21's bed and the facial mask and tubing were not in a plastic protective covering. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to provide the necessary behavior health care and services to a resident with a diagnosis of major mental illness for one (1) of 12 sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Behavioral; Health Services with a revision date of 4/28/16 revealed, Purpose: Services are provided to meet resident's psychological needs. Resident behavior and emotional needs are closely monitored and evaluated to ensure that they do not become obstacles to treatment goals. (Proper Name of Facility) provides care and services to prevent and manage behavioral problems . Record review of the Departmental Notes for Resident #23 revealed the following entries: 11/5/23, Resident called for help repeatedly to get up and lay down. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to submit a Level II Preadmission Screening and Resident Review (PASARR) to the State Mental Health (SMH) Authority for a resident with a mental disorder (MD) following a significant change in mental condition for one (1) of three (3) PASARR's reviewed. Resident #23 Findings Include: Record review of the facility policy titled Pre-admission Screening with a revision date of 2/21/19 revealed, Policy: . c. If after admission, a resident is found to have a mental illness or the physician orders a psychotropic medication for the resident a Mississippi PASRR Level 2 Change in Status request will be submitted . Record review of the Medical Doctor progress notes dated 11/14/23 revealed that Resident #23 was placed on an intervention of one on one for suicide watch due to suicidal ideation's. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to implement a comprehensive care plan for monitoring a resident for suicidal ideation for one (1) of twelve care plans reviewed. Resident #23 Findings Include: Review of the facility policy titled MDS (Minimum Data Set) 3.0; Care Plans with a revision date of 6/23/16 revealed, Policy: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required . [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to provide or arrange for the necessary mental/psychosocial counseling services for a resident with a history of mental illness and suicidal ideation for one (1) of twelve sampled residents. Resident #23 Findings Include: Record review of the facility policy titled Social Service Program with a revision date of 5/10/16 revealed under, Policy: It is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident. Also revealed under, Program Description: The Social Work Services Department is responsible for: . 4. Monitoring the resident's progress in improvement of physical, mental, and psychosocial functioning .6. Providing counseling services to residents and families . [...]

Inspectors wroteBased on staff interviews and record review, the facility failed to monitor a resident receiving anticoagulant medication for signs of bruising and bleeding for one (1) of five (5) residents reviewed for unnecessary medications. Resident #23 Findings Include: The facility provided the State Agency (SA) documentation on letterhead, (Proper Name of Facility) does not have a specific policy for monitoring for signs and symptoms of bleeding/bruising for residents on anticoagulant therapy. Record review of Resident #23's Medication Administration Record (MAR) revealed an order dated 7/14/23, Coumadin 7.5 mg (milligrams) by mouth every day except Wednesday for Circulation. Also revealed an order dated 10/20/23,Coumadin 2.5 mg tablet take one tablet by mouth on Wednesday for circulation. Both physician orders had a discontinuation date of 1/20/24. [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents during two (2) of 10 medication observations. Findings Include: Record review of the facility policy titled, Medication Administration with a revision date of 6/07/16 revealed, .Essential Points: . 3. Never leave medication on top of medication cart unattended . During an observation of medication pass with Registered Nurse (RN) #1 on 1/23/24 at 11:15 AM, Resident #3 was ordered Novolog Insulin per sliding scale for a blood glucose reading of 285 mg/dl (milligrams/deciliter). RN #1 revealed the insulin was not stored on the medication cart, and she must go get the prescribed insulin from the medication room. [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to appropriately clean and disinfect a blood glucose meter between resident use for three (3) of nine (9) residents who require blood glucose finger sticks. Findings Include: Record review of the facility policy titled, Glucose Checks with a revision date of 6/07/16 revealed, .Procedure: . 8. Clean glucometer after use for a wet time of 2 (two) minutes using purple top sani-wipe . An observation of Registered Nurse (RN) #1 on 1/23/24 at 11:02 AM, revealed after she completed a blood glucose check for Resident # 3 using a multi-use glucometer, she used a Sani-cloth (purple top) disinfecting wipe to briskly wipe down the glucometer machine for approximately five (5) seconds and placed the machine on a napkin barrier to air dry. [...]