Tishomingo Comm Living Center

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of five (5) residents who were at risk for elopement and wandering, Resident #68. On 12/10/25, at approximately 2:53 PM a member of the facility staff reported in the staff meeting that Resident #68 was found inside the pharmacy across the street. At 2:55 PM Resident # 68 was located by facility staff, approximately 100 yards away from the facility across a busy two-lane street inside the pharmacy where he was observed standing, laughing and conversing with the pharmacy staff. The temperature at the time was cloudy and 55 degrees; the resident was dressed in lace up tennis shoes, pants and a long sleeve shirt. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. 4th Quarter 2025. Findings Include:Record review of the facility policy titled, Staffing Hours-Monitoring of Policy and Procedure undated, revealed, Purpose: To assure the facility staffing meet federal and state guidelines. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2025 (July 1-September 30), revealed the facility triggered on this report for excessively low weekend staffing. During an interview on 12/17/2025 at 3:20 PM, the Administrator revealed that after auditing the low weekend staffing data, she discovered that the data submitted to PBJ was inaccurate. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide written notification to the resident/representative regarding bed hold when the resident was sent to the hospital for two (2) of two residents reviewed for hospitalization. Resident #1 and Resident #65Findings Include: Review of the facility policy titled, Bed hold Policy and Procedure revealed Policy: Before the facility transfers a resident to the hospital or allows a resident to go on therapeutic leave, written information should be provided to the resident and family member or legal representative specifying the following information: (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the facility; [...]

Inspectors wroteBased on resident and staff interviews and record review, and the facility policy the facility failed to notify the provider of an increase in blood pressure for one (1) of three (3) residents reviewed for blood pressure monitoring.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to notify the resident's representative in writing and the Ombudsman of the emergency transfer to the hospital for one (1) of two (2) residents reviewed for hospitalization.

Inspectors wroteBased on staff interview, record review and the facility policy the facility failed to develop a care plan for a resident with a history of hypertension for one (1) of 19 care plans reviewed.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to prevent the possibility of an accident while administering medications for one (1) of four (4) residents observed for medication administration. Resident #34 Findings Include: Review of the facility policy titled, Medication Administration-General Guidelines with a revision date of 8/25/14 revealed under Procedure .#1. Preparation: e. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing . An interview and observation on 07/29/24 at 10:44 AM with Resident #34 revealed that her only problem was a huge pill they give her, and she cannot swallow it. She stated it gets stuck in her throat and she just has to let it dissolve. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to ensure that the Dietary Manager (DM) had completed required training for dietary management after one year of full-time employment for four (4) or four (4) survey days observed.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to store food in a manner that meets professional standards as evidenced by unlabeled and undated food in the refrigerator, dry food stored uncovered and resident nourishment refrigerators with resident snacks that were unlabeled or undated for two (2) of four (4) survey days.

Inspectors wroteBased on record review, resident interview, staff interview, and facility policy review the facility failed to ensure a resident's Advance Directives were honored as evidenced by the facility did not correctly implement the resident's decision on the correct code status for two (2) of 24 resident's reviewed (Resident # 30 and # 51) and failed to have a copy of the Advanced Directive on the medical record for two (2) of 24 residents reviewed. (Resident # 45 and #58) Findings Include: A review of the facility policy titled, Advance Directives, reviewed 11/2022, revealed, Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .Determining Existence of Advance Directive .2. [...]

Inspectors wroteBased on observation, staff and resident interviews, and facility policy review the facility failed to respect the dignity of a resident as evidenced by not completely covering the resident's naked body while transporting the resident to the shower for one (1) of 67 resident's observed, Resident #33 Findings Include: Record review of the facility policy titled, Dignity and Respect with no revision date revealed under Procedure .#4 Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. [...]

Inspectors wroteBased on staff interview, record review and review of the statement regarding the facility's policy, the facility failed to submit a change in status for a Level II PASARR (Pre admission Screening and Resident Review) referral for one (1) of four (4) residents reviewed. Resident # 46. Findings Include: Record review of facility policy titled, admission Criteria, dated 4/25/23, revealed, Our facility admits only residents who's medical and nursing care needs can be met. The policy also revealed, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. [...]

Inspectors wroteBased on staff interview, record review, and policy review the facility failed to develop a care plan for cardio-pulmonary resuscitation code status (Resident #30 and Resident #51) and implement a care plan by failing to change a humidifier bottle and tubing, and ensuring a resident received humidified oxygen (Resident # 17) for three (3) of 24 resident reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to change an oxygen (O2) humidifier bottle and tubing weekly as ordered for one (1) of four (4) residents reviewed for oxygen therapy.