Tiffany Springs Rehabilitation & Health Care Cente

In the surveyor’s words

From the most serious findings on record at Tiffany Springs Rehabilitation & Health Care Cente, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jun 17, 2024

  Based on interview and record review, the facility failed to perform life saving measures to include Cardio-pulmonary resuscitation (CPR) for one sampled resident (Resident #1) when staff found the full code resident without a pulse or respirations. Additionally, the facility failed to ensure the staff knew safety protocols and emergency procedures when Licensed Practical Nurse (LPN) A did not know where to locate the crash cart (a cart that contains emergency equipment). The facility census was 117. The administrator was notified on [DATE] at 4:51 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Immediate jeopardy, isolatedF600Feb 15, 2023

  Based on observation, record review, and interview, the facility failed to keep two residents (Residents #1 and #2) free from physical abuse. Certified Nurse Aide (CNA) A entered Resident #1's room and began yanking the resident's sweater off of him/her. CNA A grabbed the resident by the shoulders and forcefully threw him/her on the bed. The resident was crying out ouch, stop it, do not do that. CNA A forcefully removed the resident's pants as the resident was attempting to hold on to his/her pants. CNA A grabbed the resident's arm, wrist and hand and slapped the resident's arm. Resident #2 described CNA A and said he/she had been rough using the mechanical lift to put him/her in bed on several occasions and had roughly removed his/her incontinent brief. […]

• Actual harm, isolatedF686Feb 26, 2026

  Based on observation, interview and record review the facility failed to prevent the development of an unstageable pressure injury (a severe, full-thickness wound where the base is completely covered by dead tissue) for one resident (Resident #2), of 6 sampled residents, when the facility failed to periodically check the resident's skin under a removable medical device for more than 20 days and the resident required surgery to clean the wound. The facility census was 115. Review of the facility policy titled, Skin Identification, Evaluation, and Monitoring, dated 2/2026 showed:-The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity, Communities will implement preventative measures and an individualized care plan will… […]

• Actual harm, isolatedF684Dec 31, 2024

  Based on observation, interview and record review, the facility failed to ensure three residents (Resident #1, #2, and #5) received treatment and care in accordance with professional standards of practice when the facility failed to provide timely lab testing with results. Two residents (Resident #2 & #5) were admitted to the hospital with septic shock. The facility also failed to obtain lab testing for one resident (Resident #1) who was without his/her psychotropic medication for fourteen days when the pharmacy would not provide the medication without lab results. The facility also failed to follow physician's orders for the resident when they did not administer psychotropic medication. The sample size was six residents. […]

• Actual harm, isolatedF689Nov 16, 2022

  Based on record review and interviews, the facility staff failed to maintain a safe environment for one resident (Resident #1) out of three sampled residents when Resident #1 was identified as a high fall risk and fell two times on 11/8/22 fracturing his/her right arm. The facility nurse found the resident on the floor, and told the Certified Nurse Aid (CNA) to pick the resident up from the floor. The nurse failed to assess the resident for injuries before and after the transfer from the floor to the bed. The resident had a second fall immediately after nurse left the resident's room. CNA B found the resident and picked him/her up before a nurse assessed the resident. CNA B failed to alert the nurse to that fall. On 11/14/22 the resident was in his/her room alone with the door closed. […]