Tiffany Heights

In the surveyor’s words

From the most serious findings on record at Tiffany Heights, in the surveyor’s own words.

• Actual harm, isolatedF658Aug 27, 2026

  Based on observation, interview, and record review, the facility failed to follow a physician order to apply the resident's lumbosacral orthosis (LSO) back brace prior to assisting the resident into a sitting position causing the resident to yell out in pain. This affected one of three sampled resident's. The facility census was 39.Review of the facility policy titled Pain Management, dated 05/01/25, showed:-The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents; goals and preferences;-In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or… […]

• No harm, potential for more than minimal, widespreadF812Dec 5, 2025

  Based on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to use soap and water during handwashing. The facility census was 38.Review of facility policy for Food and Nutrition Services, Hand Washing, dated 2025, showed:- Employees are expected to practice proper hand hygiene;- When to wash hands: before starting work or handing food, before putting on gloves or changing gloves, after touching body (hair, face, nose, mouth), after handling raw food or garbage or chemicals or dirty dishes, after touching anything that may contaminate hands such as door handles or equipment or carts;- How to wash hands: wet hands and forearms with warm water, apply soap and work into a lather, scrub… […]

• No harm, potential for more than minimal, patternF574Dec 5, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were able to exercise their rights when the facility did not inform residents on where to find contact information for the State Survey Agency, how to file a complaint for seven residents of the resident counsel group or where to find the Ombudsman's contact information for one sampled resident (Resident #21) and seven of 14 resident council members. The facility census was 38.Review of facility Residents' Rights Policy, dated 6/10/25, showed:- A posting of names, addresses and phone numbers of all pertinent state client advocacy groups will be available in the facility;- The resident has the right to be informed of his or her rights and of all the rules and regulations governing resident conduct… […]

• No harm, potential for more than minimal, patternF584Dec 5, 2025

  Based on observation and interview, the facility failed to ensure a clean, comfortable, and homelike environment for two residents (Residents #26 and #28) who could not obtain hot water of at least 105 degrees Fahrenheit in their rooms and for one resident (Resident #2) who had difficulty entering his/her room due to a structural impediment at the entrance door of his/her room. This affected three out of 12 sampled residents. The facility census was 38.Review of the facility policy, Safe Water Temperatures, dated 6/15/25, showed:- Staff will report abnormal findings, such as complaints of water too cold or hot, or any problems with water temperature to the supervisor and/or maintenance staff;- Water temperatures will be set to a temperature of no more than 120 degrees Fahrenheit or the… […]

• No harm, potential for more than minimal, patternF585Dec 5, 2025

  Based on interview and record review, the facility failed to ensure residents had the right to file grievances in writing, the right to file grievances anonymously, and the right to obtain a written decision regarding his or her grievance (Resident #28). This affected 12 out of the 14 residents who attended group meeting and one of the 12 sampled residents, (Resident #15). The facility census was 38. Review of facility policy, Residents' Rights, dated 6/10/25, showed:- The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. […]