A list of the most recent deficiencies for Tiffany Square. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-10-05 | 2023-11-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-05 | 2023-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-05 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-11-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-03 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-03 | 2023-11-17 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-10-03 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-03 | 2023-11-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-03 | 2023-11-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-26 | 2022-08-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-26 | 2022-08-26 | N |
| 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 | 2022-07-26 | 2022-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-26 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-26 | 2022-08-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-26 | 2022-08-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-07-20 | 2022-08-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-08 | 2021-05-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-08 | 2021-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-08 | 2021-05-06 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-04-08 | 2021-04-30 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-04-08 | 2021-04-30 | N |
