Tishomingo Manor

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure residents were treated with dignity and respect by providing adequate incontinent care supplies during the night shift for one (1) of four (4) residents sampled (Resident #4), resulting in actual psychosocial harm. Findings Include:Record review of the facility policy titled Resident's Rights Policy with a revision date of 12/23 revealed Every resident in this facility has the right to: 11. Receive adequate and appropriate health care, medical treatment and protective support services. 12. Be treated courteously, fairly, and with the fullest measure of dignity. [...]

Inspectors wroteBased on observations, resident/staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident's right to be free from involuntary seclusion for one (1) of three (3) residents on transmission-based precautions (TBP).

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for a resident with a urinary catheter and for residents with Activities of Daily Living (ADL) that required oral care, nail care, bathing, and facial grooming for two (2) or twenty-one residents sampled.

Inspectors wroteBased on observation, staff, resident, and resident representative interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath nails, unshaven facial hair, unbathed, and poor oral hygiene for three (3) of 21 sampled residents.

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review the facility failed to assure that there was sufficient qualified nursing staff available at all times to assist the residents in getting the care they needed for three (3) of 24 days of staffing reviewed.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.