Deficiency Records for Tiffany Square
Updated as of August 01, 2021
This is not the most recent data for Tiffany Square. For the most recent information, click here.
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 | 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-10-27 | 2020-11-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-10-08 | 2020-10-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-25 | 2019-08-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-07-01 | 2019-08-15 | 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 | 2019-07-01 | 2019-08-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-01 | 2019-08-15 | 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 | 2019-07-01 | 2019-08-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-01 | 2019-08-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-01 | 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 | 2019-07-01 | 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 | 2019-07-01 | 2019-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-01 | 2019-08-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-01 | 2019-08-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-01 | 2019-08-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-01 | 2019-08-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-07-01 | 2019-08-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-01 | 2019-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-01 | 2019-08-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-01 | 2019-08-15 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2019-07-01 | 2019-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-07-01 | 2019-08-15 | 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 | 2018-03-05 | 2018-04-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-05 | 2018-04-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-03-05 | 2018-04-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-07 | 2018-04-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-03-07 | 2018-04-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-07 | 2018-04-02 | 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 | 2018-03-07 | 2018-04-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-07 | 2018-04-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-07 | 2018-04-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-03-07 | 2018-04-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-07 | 2018-04-02 | 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 | 2018-03-07 | 2018-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-07 | 2018-04-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-07 | 2018-04-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-07 | 2018-04-02 | N |
