Inspection Reports for
Tishomingo Community Living Center
1410 West Quitman, Iuka, MS, 38852
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 18, 2025
Visit Reason
The inspection was conducted following complaints regarding failure to provide written bed-hold notifications to residents transferred to the hospital and failure to provide adequate supervision to prevent elopement of a cognitively impaired resident.
Complaint Details
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.
Findings
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.
Deficiencies (3)
F 0628: The facility failed to provide written notification regarding bed-hold policies to residents transferred to the hospital for two residents reviewed.
F 0689: The facility failed to provide adequate supervision to prevent the elopement of one resident at risk, placing the resident and others at risk of serious injury or death.
F 0851: The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for one quarter due to data entry errors.
Report Facts
Residents affected: 2
Residents affected: 1
BIMS score: 3
Date of survey completion: Dec 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed failure to provide written bed-hold notices for Residents #1 and #65 | |
| Administrator | Confirmed bed-hold notification policy and awareness of elopement incident | |
| Licensed Nursing Home Administrator | LNHA | Described understanding of elopement incident involving Resident #68 |
| Pharmacy Technician | Reported Resident #68 was found inside the pharmacy after elopement | |
| Licensed Practical Nurse #1 | LPN | Worked at front nursing station during elopement and described resident behavior |
| Certified Nursing Assistants #1 and #2 | CNA | Reported training and documentation changes after elopement incident |
| Director of Nursing | DON | Reported on elopement incident and corrective actions |
| Social Services #1 | SS | Reported observations and interventions related to Resident #68 |
| Licensed Practical Nurse #2 | LPN | Reported on resident behavior and documentation practices |
| Administrator | Revealed staffing data submission errors to PBJ system | |
| Director of Nurses | DON | Revealed staffing data submission errors to PBJ system |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 18, 2025
Visit Reason
The inspection was conducted following a complaint investigation triggered by the elopement of Resident #68, a cognitively impaired resident who was found outside the facility in a nearby pharmacy.
Complaint Details
The complaint investigation was substantiated. Resident #68, with severe cognitive impairment and identified as an elopement risk, eloped on 12/10/25 and was found approximately 100 yards away in a pharmacy across a busy street. The facility was notified and corrective actions were implemented promptly, including one-to-one observation, door security upgrades, staff education, and increased visual checks. Immediate Jeopardy was removed on 12/12/25 after these actions.
Findings
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of Resident #68, placing the resident and others at risk of serious injury or death. Immediate Jeopardy was identified but removed after corrective actions were implemented, including enhanced supervision, door security upgrades, staff education, and monitoring protocols.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision and a secure environment to prevent the elopement of Resident #68, who was found outside the facility across a busy street in a pharmacy. This failure placed residents at risk of serious injury or death.
Report Facts
BIMS score: 3
Distance to pharmacy: 100
Speed limit: 35
Temperature: 57
Visual check frequency: 30
Visual check frequency: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator | Described awareness and response to the elopement incident | |
| Pharmacy Technician | Reported interaction with Resident #68 during elopement | |
| LPN #1 | Licensed Practical Nurse | Worked at front nursing station on day of elopement and described resident supervision |
| LPN #2 | Licensed Practical Nurse | Worked at back nursing station and described resident interactions and documentation |
| DON | Director of Nursing | Reported knowledge of resident and facility response to elopement |
| SS #1 | Social Services | Reported observations and interventions related to resident elopement |
| CNA #1 | Certified Nursing Assistant | Reported training and documentation changes after elopement |
| CNA #2 | Certified Nursing Assistant | Reported training and documentation changes after elopement |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, notification procedures, care planning, medication administration, and accident prevention at Tishomingo Community Living Center.
Findings
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.
Deficiencies (4)
F 0580: The facility failed to notify the provider of increased blood pressure for one resident with hypertension despite multiple elevated readings over eight days.
F 0623: The facility failed to notify the resident's representative in writing and the Ombudsman of an emergency hospital transfer for one resident.
F 0656: The facility failed to develop a care plan addressing hypertension for one resident with a history of hypertension.
F 0689: The facility failed to prevent a medication administration hazard by not offering to split or crush a large pill for one resident who had difficulty swallowing.
Report Facts
Elevated blood pressure readings: 11
Care plans reviewed: 19
Residents observed for medication administration: 4
Residents reviewed for blood pressure monitoring: 3
Residents reviewed for hospitalization: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration deficiency for not offering to split or crush a large pill |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including failure to notify physician, failure to develop care plan, and medication administration oversight |
| Medical Records Nurse | Medical Records Nurse | Named in failure to notify resident's representative and Ombudsman of emergency transfer |
| MDS Registered Nurse | Minimum Data Set Registered Nurse | Named in failure to develop care plan for hypertension |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication crushing policy |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation triggered by the omission of an insulin order for Resident #1, which resulted in serious harm and death.
Complaint Details
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.
Findings
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.
Deficiencies (5)
F0655: The facility failed to develop and implement a baseline care plan for diabetes and omitted a physician-ordered insulin resulting in diabetic ketoacidosis and death of Resident #1.
F0658: The facility failed to ensure services met professional standards by inaccurately transcribing and reconciling physician's medication orders, leading to omission of insulin and death of Resident #1.
F0684: The facility failed to provide necessary care and services per professional standards, omitting insulin orders and failing to develop a comprehensive diabetes care plan for Resident #1, resulting in death.
F0760: The facility failed to ensure Resident #1 was free from significant medication errors, omitting a physician-ordered insulin for five days, resulting in diabetic ketoacidosis and death.
F0842: The facility failed to maintain accurate and complete medical records for Resident #1, omitting transcription of insulin orders and failing to develop a comprehensive care plan, contributing to the resident's death.
Report Facts
Blood sugar readings above 141 mg/dl: 14
Blood sugar reading: 764
Insulin omission duration: 5
Date of survey completion: Jun 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse on duty who found Resident #1 after fall and initiated emergency response. |
| ADON | Assistant Director of Nursing | Entered physician orders but omitted insulin order; suspended during investigation. |
| DON | Director of Nursing | Confirmed omission of insulin order and system breakdown; involved in corrective actions. |
| Medical Records Nurse | Responsible for verifying orders; failed to verify Resident #1's orders timely. | |
| Administrator | Notified of Immediate Jeopardy; involved in investigation and corrective action oversight. | |
| RNC | Registered Nurse Consultant | Conducted in-services and order reviews as part of corrective actions. |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 1, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care planning, respiratory care, dietary management, and food safety.
Findings
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.
Deficiencies (7)
F 0578: The facility failed to ensure residents' advance directives were honored, with discrepancies between residents' wishes and documented code status for four residents.
F 0583: The facility failed to respect a resident's dignity by not fully covering the resident's body while transporting to the shower.
F 0644: The facility failed to submit a required Level II PASARR status change for one resident with a new mental health diagnosis.
F 0656: The facility failed to develop and implement accurate care plans for residents' CPR code status and oxygen therapy, including failure to change humidifier bottles and tubing as ordered.
F 0695: The facility failed to provide safe respiratory care by not changing oxygen humidifier bottles and tubing weekly as ordered for one resident.
F 0801: The facility failed to ensure the Dietary Manager completed required certification training after one year of employment.
F 0812: The facility failed to store food properly, with unlabeled and undated food in refrigerators and uncovered dry food, risking resident safety.
Report Facts
Residents reviewed: 24
Residents observed: 67
Survey days: 4
BIMS scores: 10
BIMS scores: 11
BIMS scores: 13
BIMS scores: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding code status and care plan discrepancies for residents | |
| Licensed Practical Nurse (LPN) #2 | Interviewed regarding code status verification for Resident #51 | |
| Licensed Social Worker (LSW) | Interviewed regarding advance directive discrepancies and PASARR referral failure | |
| Administrator | Interviewed regarding advance directive discrepancies, care plan failures, dietary manager certification, and food storage issues | |
| Certified Nurse Assistant (CNA) #2 | Interviewed regarding dignity issue with Resident #33 | |
| Dietary Manager (DM) | Interviewed regarding lack of certification and food storage practices | |
| Registered Dietician (RD) | Interviewed regarding dietary manager certification | |
| Certified Nursing Assistant (CNA) #1 | Interviewed regarding nutrition refrigerator food storage | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding nutrition refrigerator food storage | |
| Director of Nursing (DON) | Interviewed regarding care plan accuracy, oxygen therapy, and food storage |
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