Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 30, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate provision of incontinent care supplies during the night shift at the nursing facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0550: The facility failed to ensure residents were treated with dignity and respect by providing adequate incontinent care supplies during the night shift for four of five residents sampled. Residents were required to wear bed sheets when briefs ran out, causing distress and discomfort.
Report Facts
Residents sampled with inadequate incontinent care supplies: 4
Number of briefs given per resident per day: 6
Number of briefs given per resident per day (varied): 8
Number of briefs given per resident per day (varied): 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Reported lack of access to incontinent briefs during night shift |
| Certified Nurse Aide #1 | CNA | Reported no access to briefs and use of bed sheets when briefs run out |
| Licensed Practical Nurse #2 | LPN | Described housekeeping passing out briefs and key access to environmental room |
| Certified Nurse Aide #2 | CNA | Reported ongoing issues with lack of briefs and use of bridging method |
| Laundry Worker | Passes incontinent briefs following a list of resident sizes | |
| Certified Nurse Aide #3 | CNA | Reported major shortage of briefs on night shift |
| Housekeeper #1 | Housekeeper | Passes out briefs in the morning, stated residents get six briefs daily |
| Housekeeping Supervisor | Housekeeping Supervisor | Confirmed briefing distribution and lack of extra briefs in locked room |
| Director of Nursing | DON | Confirmed no briefs available in locked room and described facility practices |
| Certified Nurse Aide #4 | CNA | Confirmed resident lying in bed without briefs and described difficulties |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 2, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, infection control, care planning, fluid restriction monitoring, and staffing data submission at Tishomingo Manor nursing home.
Findings
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.
Deficiencies (6)
F 0550: The facility failed to ensure privacy and dignity for Resident #12 during PEG tube medication administration as the nurse did not close the door or pull the privacy curtain.
F 0603: The facility failed to prevent involuntary seclusion of Resident #40 on contact isolation precautions, leading to increased anxiety and depression.
F 0656: The facility failed to implement care plan interventions for Resident #25 on a 2,000 ml fluid restriction, lacking documentation of fluid intake.
F 0692: The facility failed to accurately monitor and document fluid intake for Resident #25, making it impossible to determine adherence to fluid restriction.
F 0851: The facility failed to submit accurate Payroll-Based Journal staffing data for the 1st quarter of 2025 due to misclassification of administrative nurse hours.
F 0880: The facility failed to follow Enhanced Barrier Precautions for Resident #12 by not wearing a gown during medication administration via PEG tube.
Report Facts
Fluid restriction: 2000
Medication passes fluid allocation: 480
Meal fluid allocation: 1500
PBJ quarter: 1
Surgical wound diameter: 1
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in findings for failure to provide privacy and not wearing gown during medication administration for Resident #12 |
| Director of Nursing | DON | Confirmed nursing staff should have provided privacy and worn gown for Resident #12 |
| Licensed Practical Nurse #3 | LPN | Confirmed fluid restriction and lack of fluid intake documentation for Resident #25 |
| Certified Nursing Assistant #3 | CNA | Interviewed regarding Resident #40's isolation status and wound care |
| Treatment Nurse | Confirmed Resident #40's MRSA wound and isolation status | |
| Infection Control Nurse | IC Nurse | Confirmed MRSA presence and isolation practices for Resident #40 |
| Activities Director | Confirmed Resident #40's isolation and activity restrictions | |
| Social Services Director | Acknowledged Resident #40's isolation and mental health concerns | |
| Medicare Nurse | Case manager for Resident #40, confirmed wound status and isolation | |
| Social Services #1 | Psychiatric Social Worker | Provided mental health visits and documented Resident #40's anxiety and depression |
| Staff Development Nurse | Discussed staffing needs and Payroll-Based Journal data issues | |
| Administrative Assistant | Handled payroll and discussed PBJ submission inaccuracies | |
| Director of Special Projects | Submitted PBJ data and discussed lack of CMS notifications | |
| Regional Nursing Consultant | Acknowledged PBJ data inaccuracies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 22, 2024
Visit Reason
The inspection was conducted due to a complaint regarding medication administration errors and inaccurate staffing data submission in the Payroll-Based Journal (PBJ) system.
Complaint Details
The complaint investigation found substantiated issues with medication administration errors and inaccurate staffing data submission for the first quarter of 2024.
Findings
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.
Deficiencies (2)
F 0759: The facility failed to maintain a medication administration error rate below 5%, with four of 25 medication administrations observed in error. Medications, including extended release potassium, were crushed and administered together without approval.
F 0851: The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for one of four quarters reviewed. Manual entry errors led to underreporting of nursing administrative staff hours on weekends.
Report Facts
Medication administration opportunities: 25
Medication administration errors: 4
Medication error rate: 16
PBJ quarters reviewed: 4
PBJ quarter with error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Involved in medication administration error by crushing medications not approved to be crushed | |
| Pharmacy Consultant | Confirmed potassium extended release should not be crushed and provided in-service training | |
| Administrator (ADM) | Interviewed regarding PBJ staffing data submission errors | |
| Administrative Assistant | Responsible for manual input of agency staff hours into PBJ system |
Inspection Report
Routine
Deficiencies: 6
Date: May 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse reporting, care planning, personal hygiene, catheter care, and staffing adequacy at Tishomingo Manor nursing home.
Findings
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.
Deficiencies (6)
F 0550: The facility failed to provide dignity to residents by leaving urinary catheter bags uncovered and not serving meal trays concurrently to residents at the same table.
F 0609: The facility failed to timely report an incident of resident-on-resident abuse within the required two-hour timeframe for one resident.
F 0656: The facility failed to develop and implement a comprehensive care plan for a resident with a urinary catheter and for residents requiring assistance with oral care, nail care, bathing, and grooming.
F 0677: The facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath, unshaven facial hair, unbathed residents, and poor oral hygiene for three residents.
F 0690: The facility failed to ensure appropriate catheter care by not securing the catheter tubing with a leg strap for one resident, risking catheter dislodgement or bladder spasms.
F 0725: The facility failed to provide sufficient qualified nursing staff at all times to meet resident care needs for three of 24 days reviewed, resulting in inadequate care including missed showers and delayed responses to call lights.
Report Facts
Residents requiring two-person physical assistance: 16
Residents requiring staff assistance to be fed: 17
Days with insufficient staffing: 3
Call lights observed sounding: 3
Dates with missed oral care for Resident #5: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed no privacy cover for Resident #244's urinary catheter bag and acknowledged dignity issue. |
| Director of Nursing | DON | Confirmed catheter bag dignity issue, failure to serve meals concurrently, inadequate care plan implementation, and staffing shortages. |
| Certified Nurse Aide #5 | CNA | Reported staffing struggles and confirmed usual two aides per hall. |
| Registered Nurse #1 | RN | Inquired about dining tray distribution process and confirmed trays should be served concurrently. |
| Certified Nurse Aide #7 | CNA | Confirmed Resident #39 did not receive shower or shave on scheduled day. |
| Corporate Nurse | Nurse | Confirmed ongoing staffing concerns and failure to hold admissions due to low staffing. |
| Assistant Director of Nursing | ADON | Confirmed staffing shortages, use of agency staff, and efforts to manage call-ins and scheduling. |
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