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Deficiency Records for Tiffany Springs Rehabilitation and Health Care Cente
A list of the most recent deficiencies for Tiffany Springs Rehabilitation and Health Care Cente. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Tiffany Springs Rehabilitation and Health Care Cente. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-31 | 2025-01-31 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-12-31 | 2025-01-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-10-04 | 2024-11-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-10-04 | 2024-11-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-10-04 | 2024-11-08 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-10-04 | 2024-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-04 | 2024-11-08 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-10-04 | 2024-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-10-04 | 2024-11-08 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-10-04 | 2024-11-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-04 | 2024-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-10-04 | 2024-11-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-10-04 | 2024-11-08 | Y |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2024-10-02 | 2024-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-02 | 2024-11-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-08-21 | 2024-09-06 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-06-17 | 2024-07-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-02-13 | 2024-03-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-13 | 2024-03-19 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-18 | 2023-10-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-18 | 2023-09-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-18 | 2023-09-22 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-18 | 2023-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-18 | 2023-09-22 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-08-18 | 2023-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-18 | 2023-09-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-18 | 2023-09-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-15 | 2023-03-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-12-16 | 2023-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-16 | 2022-12-08 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-08 | 2022-10-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-17 | 2022-06-15 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-24 | 2022-03-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-24 | 2022-02-23 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-11-24 | 2022-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-24 | 2022-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-24 | 2022-02-23 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-11-24 | 2022-01-07 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2021-11-24 | 2022-01-07 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-11-24 | 2022-01-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-11-24 | 2022-01-07 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-24 | 2022-01-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-24 | 2022-01-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-24 | 2022-01-07 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-11-24 | 2022-01-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-11-24 | 2022-01-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-24 | 2022-01-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-24 | 2022-01-07 | N |
| Keep all essential equipment working safely. | Health | 2021-11-24 | 2022-01-07 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-24 | 2022-01-07 | N |
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