Deficiency Records for Tiffany Hall Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Tiffany Hall Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-09 | 2023-12-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-09 | 2023-12-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-09 | 2023-12-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-09 | 2023-12-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-09 | 2023-12-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2023-12-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-20 | 2022-10-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-20 | 2022-10-04 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-20 | 2022-10-04 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-14 | 2022-08-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-14 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-14 | 2022-08-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-14 | 2022-08-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-14 | 2022-08-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-14 | 2022-08-08 | N |
| 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 | 2021-07-07 | 2021-08-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-07 | 2021-08-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-06-24 | 2021-07-24 | 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 | 2021-06-24 | 2021-07-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-24 | 2021-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-24 | 2021-07-24 | 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 | 2021-06-24 | 2021-07-24 | Y |
