Inspection Reports for
Tishomingo Manor

Two complaint investigations (CI MS #3070317 and CI MS #3074482) were conducted during the survey. No deficiencies were cited related to these complaints.

The facility was found not in compliance with multiple regulatory requirements including management of personal funds, abuse/neglect policies, admissions policies, MDS accuracy, care planning, range of motion services, medication labeling and storage, and resident record maintenance. Deficiencies were cited for failure to safeguard resident funds, failure to report misappropriation, improper financial agreements, inaccurate MDS coding, incomplete care plans, failure to implement therapy recommendations, medication labeling errors, improper medication storage, and incomplete clinical documentation.

The facility met all applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.

Complaint number CI MS #2742900 investigated regarding admission, transfer, and discharge rights; no deficiencies were cited and the complaint was not substantiated.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.

The facility was found to be in substantial compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and is recommended to be placed back in compliance effective 01/20/26.

Three complaint investigations were conducted: CI MS #2617234 and CI MS #2667879 resulted in deficiencies cited (M500) related to resident rights; CI MS #2700637 was investigated with no deficiencies cited.

The facility failed to ensure residents were treated with dignity and respect by providing adequate incontinent care supplies during the night shift for one of four residents sampled, resulting in actual psychosocial harm. Multiple staff and residents confirmed a shortage of incontinent briefs at night, requiring use of bed sheets as a substitute, causing distress to residents.

The complaint investigation found substantiated issues with incontinent care supplies, including lack of access to briefs during night shifts and residents being forced to use bed sheets instead. Resident #4 expressed mental anguish due to this issue.

The facility failed to provide adequate incontinent briefs during the night shift for four of five residents sampled, resulting in residents having to wear bed sheets instead. Staff and residents reported shortages of briefs, and observations confirmed no extra briefs were available in the locked environmental room.

Complaint Investigation (CI MS #504896, CI MS #504905, CI MS #504907, CI MS #504908, CI MS #2570811, CI MS #2576051, CI#2579983, and CI MS #2568670) was conducted and the facility was determined to be in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and there were no deficiencies cited.

The SA is recommending that your facility be placed back in compliance effective 4/29/25. No deficiencies were cited during this revisit.

The State Agency is recommending that the facility be placed back in compliance effective 04/29/25.

The facility was found deficient in maintaining resident dignity and privacy during medication administration, preventing involuntary seclusion for a resident on isolation, implementing care plan interventions for fluid restriction, accurately monitoring and documenting fluid intake, submitting accurate Payroll-Based Journal staffing data, and following Enhanced Barrier Precautions for infection control.

Complaint investigations CI MS# 27587, CI MS#28336 and CI MS#28360 were investigated with no deficiencies cited.

The survey identified deficiencies in resident rights, involuntary seclusion, care planning, nutrition/hydration, payroll-based journal reporting, and infection prevention and control. The facility failed to ensure resident dignity and privacy, freedom from involuntary seclusion, implementation of care plans, accurate fluid intake documentation, accurate staffing data submission, and proper use of enhanced barrier precautions.

The facility was found in compliance with all emergency preparedness and Life Safety Code requirements. There were no deficiencies cited during this survey.

Complaint number CI MS # 26840 investigated toileting and incontinent care; the SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirmed and state licensure requirements. No deficiencies were cited.

The SA is recommending that your facility be placed back in compliance effective 06/14/24. No deficiencies were cited in this desk review.

During the survey the SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and no state deficiencies were cited.

The facility was found not in compliance with Medicare and Medicaid requirements due to a medication administration error rate of 16% and failure to submit accurate staffing data into the Payroll Based Journal system for one quarter.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code and was found in compliance with no deficiencies cited.

The complaint investigation found substantiated issues with medication administration errors and inaccurate staffing data submission for the first quarter of 2024.

The facility failed to maintain a medication administration error rate below 5%, with a 16% error rate observed. Additionally, the facility submitted inaccurate staffing data to the PBJ system for the first quarter of 2024 due to manual entry errors.

Complaint investigation CI MS #22150, CI MS #22187, CI MS #22195, and CI MS #22244 were conducted and found no deficiencies; the facility was in compliance.

The survey determined that the facility was in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements with no deficiencies cited.

The facility was found not in compliance with multiple requirements including resident dignity, timely abuse reporting, comprehensive care planning, activities of daily living care, catheter care, and sufficient staffing.

K0211 - Means of egress were obstructed by folded, mounted keyboards extending beyond handrails in the main corridors, affecting exit access in four of five smoke compartments. The facility failed to maintain clear exit egress as required.

The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering urinary catheter bags and serving meals concurrently; failure to timely report resident-on-resident abuse; failure to develop and implement comprehensive care plans; inadequate personal hygiene care for residents; improper catheter care; and insufficient nursing staff to meet resident care needs.

Complaint survey completed on 09/08/22; the facility was found in compliance and no deficiencies were cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending the facility be placed back in compliance effective 10/11/22.

Complaint investigation CI MS# 19328 was substantiated for resident abuse involving sexual abuse of Resident #1. CI MS# 19435 related to quality of care was not substantiated.

The facility was found not in compliance with Medicare and Medicaid regulations and cited deficiencies at F0600 and F0609 related to failure to prevent sexual abuse and failure to timely report alleged abuse. The facility substantiated sexual abuse of Resident #1 by CNA #1 and terminated the employee.

The SA determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid effective 5/23/2022.

Complaint investigation CI MS #18566 related to falls/accidents and monitor/assess was substantiated with deficiencies cited at F580 (failure to notify), F600 (neglect), and F697 (pain management). CI MS #18370 for misappropriation, inappropriate feeding and denied visitation was not substantiated.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to notify the resident representative after a fall resulting in fracture, neglect in nursing services following the fall, and inadequate pain management for the resident. Resident #9 experienced a fall with injury and delayed notification and treatment.

The State Agency determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid.

The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

F0686 - The facility failed to provide treatment to a wound for Resident #29 consistent with professional standards of practice, including improper wound care technique that risked spreading infection among multiple wounds on the resident's toes.

CI MS #16948: The investigation was unsubstantiated with no deficiencies cited for Neglect, Quality of Care related to Services Not Received Per Physician Orders, and Infection Control. CI MS #16971: The investigation was unsubstantiated with no deficiencies cited for Infection Control and Physical Environment related to Infection Control Practices.

The facility was found to be in compliance with infection control regulations and Medicare and Medicaid requirements. Both complaint investigations were unsubstantiated with no deficiencies cited.