5 Reports
Inspection Report — Feb 10, 2025
Plan of Correction State
Date: Feb 10, 2025
Visit Reason
The document is a plan of correction submitted following a survey completed on 02/10/2025 regarding proper care per individual service plan at Tiffany Springs Senior Care Community.
Findings
The facility failed to provide proper care for residents as defined in their individualized service plans, specifically failing to provide adequate assistance during transfers which resulted in a resident falling and fracturing their leg. The deficiency was supported by interviews, record reviews, and incident reports.
Deficiencies (1)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan was not met as the facility failed to provide adequate assistance to a resident during transfer, resulting in a fall and fractured leg.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant B | Certified Nursing Assistant | Named in fall incident and transfer assistance finding |
| Certified Nursing Assistant A | Certified Nursing Assistant | Assisted resident after fall and involved in transfer |
| Licensed Practical Nurse A | Licensed Practical Nurse | Evaluated resident after fall |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding medication passing and fall incident |
| Facility Administrator | Administrator | Interviewed regarding staff assistance and transfer procedures |
Inspection Report — Dec 11, 2024
Plan of Correction State
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to medication storage and handling at Tiffany Springs Senior Care Community, specifically concerning Schedule II controlled substances and medication security.
Findings
The facility failed to ensure Schedule II controlled substances were stored securely behind two locks, resulting in missing Oxycodone medication. Investigations revealed lapses in narcotic handling, documentation, and storage procedures involving multiple staff members.
Deficiencies (1)
19 CSR 30-86.047(41)(B) Medication Storage-Schedule II: The facility failed to store Schedule II controlled substances in locked compartments separate from non-controlled medications with at least two locks, leading to missing Oxycodone medication.
Report Facts
Medication tablets: 360
Medication doses missed: 6
Medication cards delivered: 84
Medication cards for assisted living unit: 66
Medication cards for memory care unit: 18
Medication cards for Resident #1: 12
Pills per card: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Involved in handling and storage of medications during the incident | |
| CMT A | Certified Medication Technician | Handled medication delivery and storage; involved in narcotic handling |
| CMT B | Certified Medication Technician | Assisted with medication delivery and inventory |
| Administrator | Notified of missing medication and conducted investigation | |
| Assistant Director of Nursing | ADON | Directed medication storage and involved in narcotic handling |
Inspection Report — Oct 9, 2024
Plan of Correction State
Date: Oct 9, 2024
Visit Reason
The document is a plan of correction related to a deficiency found during a fire alarm system inspection on 10/09/2024.
Findings
The facility failed to have the complete fire alarm system inspected by an approved qualified service representative as required annually. The last inspection was conducted on October 2, 2023, and the facility census was 76 residents potentially affected.
Deficiencies (1)
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications: The facility failed to have the complete fire alarm system inspected by an approved qualified service representative at least annually. The last inspection was on October 2, 2023.
Report Facts
Inspection Report — Jul 20, 2023
Plan of Correction State
Date: Jul 20, 2023
Visit Reason
The document is a plan of correction related to deficiencies identified during a facility inspection on 07/20/2023 at Tiffany Springs Senior Care Community.
Findings
The facility failed to meet several fire safety and equipment regulations, including smoke section door self-closing, sprinkler system maintenance, use of approved wastebaskets, and proper oxygen storage. Observations and interviews confirmed these deficiencies affecting all 70 residents present.
Deficiencies (4)
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to ensure each door in a smoke section was capable of self-closing, with mechanical wedges blocking doors in multiple rooms.
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to ensure monthly pressure gauge readings and valve position checks of the sprinkler system were done as required, missing main riser checks.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure all wastebaskets were approved metal or fire-resistant types, with multiple non-approved wastebaskets found throughout the facility.
19 CSR 30-86.022(17) Oxygen Storage Requirements. The facility failed to ensure oxygen was stored according to NFPA 99, 1999 Edition, with untracked spare oxygen bottles found in resident rooms.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding corrective actions for sprinkler system, door issues, wastebaskets, and oxygen storage | |
| Maintenance person assisting | Interviewed about door hold magnets installation |
Document — Dec 27, 2023
State
Date: Dec 27, 2023
Visit Reason
The document does not contain any readable information to determine the visit reason.
Findings
No findings or content are available due to lack of readable text.
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