Deficiency Records for Tiffany Springs Rehabilitation and Health Care Cente
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-24 | 2022-02-23 | Y |
| 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 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-02-23 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-02-10 | 2022-02-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-10 | 2022-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-02-23 | Y |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2021-11-24 | 2022-01-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-24 | 2022-01-07 | Y |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-24 | Y |
| 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 | 2021-06-08 | 2021-07-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-08 | 2021-07-02 | Y |
| 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 | 2021-04-15 | 2021-05-07 | Y |
| 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 | 2021-04-15 | 2021-05-07 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-15 | 2019-10-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-07-15 | 2019-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-15 | 2019-08-15 | 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 | 2019-07-15 | 2019-08-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-15 | 2019-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-15 | 2019-08-15 | N |
| 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 | 2019-07-15 | 2019-08-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-07-15 | 2019-08-15 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-07-15 | 2019-08-15 | 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 | 2019-07-15 | 2019-08-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-15 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-15 | 2019-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-07-15 | 2019-08-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-15 | 2019-08-15 | N |
