Inspection Reports for
Tishomingo Community Living Center

Complaint Investigations CI MS #2987164 and CI MS #2993496 were conducted; the facility was found in compliance with no deficiencies cited.

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

CI MS #2719782 investigated allegations of abuse, neglect, quality of care, and resident rights; the complaint was not substantiated and no deficiencies were cited.

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 SA is recommending that the facility be placed back in compliance effective 01/14/26. No deficiencies were cited in this desk review.

The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and all Federal, State, and local emergency preparedness requirements. No deficiencies were cited during this survey.

The complaint investigation substantiated that the facility failed to provide written bed-hold notifications to residents transferred to the hospital and failed to prevent the elopement of a cognitively impaired resident. Immediate jeopardy was identified for the elopement incident but was removed after corrective actions were implemented.

The facility failed to provide written bed-hold notifications to two residents transferred to the hospital. Additionally, the facility failed to prevent the elopement of one resident at risk, resulting in immediate jeopardy which was later removed after corrective actions. The facility also failed to submit accurate staffing data to the Payroll-Based Journal system for one quarter.

Two complaint investigations were conducted: CI MS#2596183 for physical environment with no deficiencies cited, and CI MS#2690998 for Accident Hazards where an Immediate Jeopardy was identified due to Resident #68's elopement. The Immediate Jeopardy was removed after corrective actions.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to provide adequate supervision to prevent elopement of Resident #68, resulting in an Immediate Jeopardy that was later removed after corrective actions. Additional deficiencies were cited for failure to provide written bed-hold notices for hospitalized residents and inaccurate staffing data submission.

Complaint Investigation CI MS #470803 and CI MS #2563106 were conducted and the facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint investigation CI MS# 27378, CI MS# 27673, CI MS# 27774, CI MS# 27882, and CI MS# 28084 were conducted regarding infection control, pressure sores, personal belongings, environment heat and air, food supply, quality of care, therapy, and pressure sores. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined that the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.

Complaint Investigation (CI) MS # 26994 was conducted and no deficiencies were cited; the complaint was determined to be unsubstantiated.

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.

Two complaint investigations (CI MS #26302 and CI MS #26326) were conducted and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid Services requirements and no deficiencies were cited.

The State Agency is recommending that the facility be placed back in compliance effective 08/22/24. No deficiencies were cited in this desk review.

The SA is recommending that your facility be placed back in compliance effective 08/22/24. No deficiencies were cited in this desk review.

The facility failed to notify the physician of elevated blood pressure readings for a resident with hypertension, failed to notify the resident's representative and Ombudsman of an emergency hospital transfer, failed to develop a care plan for a resident with hypertension, and failed to prevent a medication administration hazard by not offering to split or crush a large pill for a resident.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing failures in notifying physicians of changes, notice requirements before transfer, development of care plans, and accident hazard prevention.

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 #22294 was investigated and found to be unsubstantiated as no deficiencies were cited.

The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint investigation CI MS #22098, CI MS #22204, and CI MS #22232 were conducted and the facility was found in compliance with no deficiencies cited.

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

The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 Edition of the Life Safety Code. The SA is recommending that your facility be placed back in compliance effective 6/22/23.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements at the time of this follow up visit.

Complaint investigations were conducted for CI MS #21345 (Respect/Resident Rights) and CI MS #21398 (Physical Environment) with no deficiencies cited. CI MS #21656 related to the death of a resident was substantiated with deficiencies cited.

The facility was found not in compliance with multiple deficiencies including failure to ensure dietary manager certification, respect resident dignity, proper oxygen equipment maintenance, and safe food handling. The facility identified an Immediate Jeopardy related to medication errors resulting in a resident's death, which was removed prior to exit.

The complaint investigation was initiated due to the omission of a physician-ordered long-acting insulin for Resident #1, which was not administered for five days after admission. This omission led to diabetic ketoacidosis and the resident's death. The investigation found systemic failures in order transcription, verification, and care planning.

The facility failed to accurately transcribe, reconcile, and verify physician's orders for Resident #1, leading to the omission of a long-acting insulin order. This failure resulted in diabetic ketoacidosis and the resident's death. The facility also failed to develop a baseline and comprehensive care plan for diabetes. Corrective actions including staff in-services, admission audits, and monitoring procedures were implemented and validated by the State Agency.

The facility was found to have two deficiencies related to employee criminal background checks and medical records management. The facility failed to perform a criminal background check for one employee and failed to accurately transcribe and implement physician's orders for a newly admitted resident, resulting in the resident's death.

The facility failed to honor residents' advance directives accurately, failed to maintain resident dignity during care, did not submit required PASARR status changes, failed to develop accurate care plans for code status and oxygen therapy, did not ensure timely dietary manager certification, and failed to store and label food properly in nourishment refrigerators.

K0211 - The facility failed to properly maintain exit egress as the exit doors near Resident Room 228 did not disengage and open upon activation of the fire alarm system, affecting two smoke compartments and 22 residents. The issue was acknowledged by the Administrator and Maintenance Supervisor during the exit interview.

The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.

Complaint CI MS# 20229 regarding physical environment related to scabies and bedbugs was investigated and found to be unsubstantiated with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint numbers MS00019686 and MS00019621 involved allegations of resident food services not honored, therapeutic diet not served, pharmaceutical services, and an outbreak of bed bugs. Both complaints were not substantiated.

The SA did not substantiate either complaint allegation and determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid Services.

The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).

The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.

Complaint investigation CI MS#26995 was conducted on 7/13/21. The facility was found in compliance and no deficiencies were cited.

The facility was found to have put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation and state licensure requirements. The State Agency is recommending the facility be placed back in compliance effective 7/30/21.

Complaint Investigation (CI) MS #17855 was substantiated for limiting and denying residents visitation with deficiencies cited. Complaint Investigation CI MS #17877 for alleged neglect, quality of care, and quality of life was not substantiated.

The facility failed to allow three of five residents reviewed to visit with family and friends in their private rooms, restricting visitation to pre-arranged appointments in the lobby, outside, or community room. Residents and their representatives expressed distress and dissatisfaction with the visitation limitations, which were not yet updated to allow in-room visits except for palliative or bedfast residents.

The facility was found deficient for failing to provide smoke detection systems in spaces open to corridors as required by NFPA 101 section 19.3.6.1, affecting one smoke compartment and 14 residents.

Complaint investigations MS00017174 (abuse), MS00017392 (staffing), MS00017721 (quality of care and treatment, resident rights, dietary services), MS00017455 (physical environment), and MS00017500 (resident rights) were conducted and found not substantiated.

During the survey, the State Agency determined that the facility was in compliance with Medicare and Medicaid regulations of participation and found that the complaints were not substantiated.

CI MS #16761: Complaint investigation regarding Quality of Care related to Improper Infection Control and Resident Rights related to Resident not Treated with Dignity was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Improper Infection Control or for Resident Rights related to Resident not Treated with Dignity. The facility was found in compliance with Medicare and Medicaid requirements for participation.

The facility was found in compliance with Medicare and Medicaid requirements for Emergency Preparedness. No deficiencies were cited during this survey.

Complaint number CI MS# 16663 involved a complaint of Quality of Care and was not substantiated; no deficiencies were cited.

These concerns were not substantiated and no deficiencies were cited. The facility was determined to be in substantial compliance with the requirements for participation in Medicare and Medicaid.

Complaint MS CI 00016494 alleged a fall with fracture and quality of care concerns for Resident #1; these concerns were not substantiated and no deficiencies were cited.

These concerns were not substantiated, and no deficiencies were cited.

Complaint number CI MS 00016494 involved allegations of a fall with fracture and quality of care concerns for Resident #1. The concerns were not substantiated and no deficiencies were cited.

These concerns were not substantiated, and no deficiencies were cited. The facility was found to be in substantial compliance with requirements for participation in Medicare and Medicaid.

CI MS# 16238: Concerns related to drug diversion were substantiated, but no deficiencies were cited.

The concerns related to drug diversion were substantiated, but no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with several deficiencies related to resident accommodations, self-determination, comprehensive care planning, food quality, and food safety. The facility failed to accommodate resident needs, honor food preferences, follow care plans, provide palatable meals, and store food safely.

The facility was found to have deficiencies related to residents' rights and food preparation. The facility failed to honor resident food preferences and provide appealing, palatable meals to several residents.