Tiffany Heights

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care for two of 12 sampled residents (Resident #39 and #40). The facility census was 38. Review of the facility's policy, Perineal Care, dated 5/2/25, showed:- It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown;- Perform hand hygiene and put on gloves;- Cleanse all of the genital areas in the direction from front to back;- Use a clean portion of the washcloth or new disposable wipe with each stroke;- Cleanse the bottom of the genital area and the anal area from the front to the back; - Remove gloves and discard. Perform hand hygiene. 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary behavioral care and services for one of 12 sampled residents (Resident #16's), psychosocial well-being when staff did not address the resident's sexual behavior or offer alternative ways for the resident to deal with behaviors. The facility census was 12. The facility did not provide a policy for behaviors. 1. Review of Resident #16's care plan, revised 9/25/25 showed:- The resident had a behavior problem related to his traumatic brain injury. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Nighttime cares will be completed with two staff members in room at all times. When behaviors occur, report to charge nurse for redirection. - The resident has a communication problem related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to submit the Payroll Based Journal data (PBJ, a report that provides staffing data set information submitted by nursing homes on a quarterly basis) correctly for Quarter 3, 2025 (April 1 to June 30) which had the potential to affect all residents. The facility census was 38. The facility did not have a policy for reporting direct care staffing information. Review of the facility's PBJ Staffing Data Report, showed the facility failed to have licensed nursing coverage 24 hours per day on 4/2/25, 4/12/25, 4/15/25 and on 6/6/25.Review of the daily staffing sheets shoed the facility did have licensed nursing coverage 24 hours per day on 4/2/25, 4/12/25, 4/15/25 and on 6/6/25.During an interview on 12/2/25 at 10:00 A.M., the Administrator said:The facility always had a licensed nurse on duty for eight hours on every shift.The facility does not fill out the staffing information for the PBJ, that it done by the corporate office. It should be filled out correctly.

Based on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not properly set up enhanced barrier protection for one resident (Resident #29) and failed to ensure catheter tubing and dignity bag did not drag on the ground while resident was in a wheelchair (Resident #29). This affected one of 12 residents sampled. The facility census was 38. Review of facility policy, Enhanced Barrier Precautions, dated 4/10/25, showed:- It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms;- All staff receive training on enhanced barrier precautions upon hire and as needed and are expected to comply with all designated precautions;- All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions;- An order for enhanced barrier precautions will be obtained for residents with pressure ulcers, diabetic foot ulcers, unhealed surgical wounds,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #6, #34, and #31) were assessed as safe to self-administer medications when medications were left at bedside table unattended by licensed staff. This affected three of the twelve sampled residents. The facility census was 37. Review of facility policy, self-administration of medications, dated March 2017, showed: -Staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including the resident's: -ability to read and understand medication labels; -comprehension of the purpose and proper dosage and administration time of his or her own medications; -ability to remove medications from a container and to ingest and swallow (or otherwise administer)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to consider the views of the resident council and act promptly upon grievances and recommendations made by the group concerning issues of resident care and life in the facility when the facility failed to demonstrate their response and rationale for such responses. The facility additionally failed to maintain documentation of attempts to resolve concerns, or the facility's communication to the council on follow up actions. This affected eight of eight residents serving on the resident counsel and potentially other residents of the facility. The facility census was 37. Review of facility policy, Resident Council, 4/2017, showed: - A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to obtain a signature from the resident or or resident's legal representative on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms prior to discharging from Medicare services for two residents (Resident #23 and #13) out of three sampled residents. The facility census was 37. Review of form instructions skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) Form CMS-10055, dated 4/8/2014, showed: -Signature and date: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The skilled nursing facility may fill in the date if the beneficiary needs help. The date should reflect the date the SNF gave therm notice to the beneficiary in-person or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for he beneficiary, write 'rep' or representative next to the signature. If the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain the privacy of three of the 12 sampled residents, (Resident #10, #17 and #32), when staff failed to post signage at the front door or outside each sampled resident's rooms to indicate 24 hour camera surveillance was in progress and failed to obtain consents from the responsible parties of the sampled residents. The facility census 37. Review of the facility's policy for videotaping, photographing, and other imaging of residents, revised April, 2027, showed, in part: - Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities; - For the purpose of this policy, resident image means the likeness of a resident captured through still digital images, and recordings during resident care or other facility activities; - The facility policy did not address the use of camera surveillance, posting of camera…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for five residents when the care plan failed to address five resident's code status wishes (Resident #18, #34, #6, #8, and #25). This affected five of twelve sampled residents. The facility census was 37. Review of facility policy, care plans, comprehensive person-centered, undated, showed: -A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. -The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. -Reflect on the resident's expressed wishes regarding care and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe's to meet the residents medical, nursing, mental, and psychosocial needs for six residents (#7, #27, #34, #17, #18,#6) of the12 sampled residents. The facility census was 37. Review of the facility's undated Care Plan Policy showed: - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. - The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care for four of the 12 sampled residents when staff installed side rails without a physician's order which affected one sampled resident, (Resident #18); failed to obtain orders for self-administration of drugs for one sampled resident, (Resident #34); failed to follow physician orders for medications (Resident #31) and immobilizer (Resident #34), and left blanks in the documentation on the MAR (Medication Administration Record) for one resident (Resident #6). The facility census was 37. The facility did not provide a policy on professional standards of care. Review of the facility policy regarding documentation of medication administration, showed: - The facility shall maintain a medication administration record to document all medications administered. - Administration of medication must be documented immediately after (never before) it is given. Review of the facility policy regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected two residents (Residents #12 and #29) out of 12 sampled residents. The facility census was 37. Review of the facility's Activities policy, revised August 2006, showed, in part: - Activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs; - Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs; Review of the facility's Activities Documentation policy, revised December 2009, showed, in part: -Recordkeeping is a vital part of the activity programs; - Activity Department personnel will maintain records…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure they obtained a signed and dated statement from the pharmacist when no irregularities were identified during the medication regimen review, and when the pharmacist date of review and name was not listed on any medication regimen reviews. Failed to provide documentation that a monthly medication regimen review was completed, and failed to provide documentation that the medication regimen review was provided to the physician monthly. This affected five of the twelve sampled residents (Resident #6, #18, #3, #7 and #27). The facility census was 37. Review of facility policy, Medication Regimen Review, Revised April 2007, showed: -The consultant pharmacist shall review the medication regimen of each resident at least monthly. -Consultant pharmacist will perform a medication regimen review (MRR) for every resident in the facility. -The Consultant Pharmacist will document his/her findings and recommendation on the monthly drug/medication regimen review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent. Staff made two medication errors out of 25 opportunities for error, resulting in a medication error rate of 8%. This affected two of the 12 sampled residents, (Resident #16 and #32). The facility census was 37. Review of the facility's undated policy for nasal drops/spray medication administration showed: - Withdraw the medication into the dropper or uncap the spray or squeeze bottle if this is the type of dispenser used; - Ask the resident to breathe through the mouth during the administration. Review of the package leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature when cooked foods were not temperature checked and finished products were held on the steam line in excess of three hours for 6 of 8 residents sampled (Resident #6, #7, #17, #27, #34, #36). The facility census was 37. No policy on required temperature checks of cooked food was provided. Review of facility policy, food safety and sanitation, undated, showed: -There was no guidance on how to prepare, distribute, and serve food in accordance with professional standards for food safety. Review of facility policy, assistance with meals, revised September 2013, showed: -For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility staff failed to maintain an effective infection control program when staff did not ensure residents with open wounds (Resident #18) and catheters (#17) were placed on enhanced barrier precautions (EBP) and when clean laundry was not covered during transportation in the facility. This affected two of the 12 sampled residents (Residents #18, and #17). The facility census was 37. Review of facility policy, infection control, dated 3/2020, showed: -It was the policy of the facility to protect residents and staff from communicable diseases and infections. -For residents for whom enhanced barrier precautions (EBP) are indicated, EBP is employed when performing the following high -contact resident care activities: -Dressing -Bathing/Showering -Transferring; -Providing Hygiene; -Changing linens -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube tracheostomy/ventilator; -Wound care: any skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent a urinary tract infection(UTI) or the possibility of a UTI for one of the 12 sampled residents, (Resident #1). The facility census was 37. Review of the facility's undated policy for indwelling urinary catheter, showed, in part: - Position the resident on their back; - Wash around the catheter insertion site and then from the tip of the skin fold down to the body, including all skin folds; - Cleanse approximately 1/3 of catheter tubing from the insertion site. 1. Review of Resident #1's care plan, revised 5/28/24 showed: - The resident had an indwelling catheter related to obstructive uropathy (a urinary tract condition that occurs when urine flow is blocked, causing urine to back up into the kidneys). Position the catheter bag and tubing below the level of the bladder and away from entrance room door. Change the 18 french (fr.) catheter monthly. Monitor, record, report to physician for signs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to follow their policy for storage of medications when they stored food and medication in the medication refrigerator. This had the potential to affect all the residents in the facility. The facility census was 37. Review of the facility's undated policy for storage of medications showed, in part: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; - Medications requiring refrigeration must be stored in a refrigerator per the manufacturer recommendation and located in the drug room at the nurse's station or other secured location; - Medications must be stored separately from food and must be labeled accordingly. 1. Observation and interview on 8/27/24 at 11:46 A.M., of the medication room showed: - The medication refrigerator had at least 15 containers of applesauce and nine containers of Med Pass (oral nutritional supplement) and two small containers of tomato juice; - Licensed Practical Nurse (LPN) A said it was used for medication pass. During an interview on 8/29/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to store food in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 42. Review of the facility's Labeling/Dating Foods policy, dated 2011, showed: -All foods stored will be properly labeled according to the following guidelines -Date marking for dry storage items: Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation. Once a case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. The Exception: to date individual dry storage items includes individually packaged food items stored in bulk containers such as packets of hot chocolate, tea bags, saltine crackers, packets of individual cookies, etc. The Dining Services Manager is to ensure that these bulk items are rotated with old items used first. New…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.