Tiffany Hall Nursing and Rehab Center

Total Number of Beds: 120	Percent of Occupied Beds: 85%
Total Number of Residents: 102	Located Within a Hospital: No
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 04/03/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.4

Number of LPN/LVN Hours per Nursing Home Resident per Day: 1.1

Number of CNA Hours per Nursing Home Resident per Day: 2.7

Number of Staff Hours per Nursing Home Resident per Day: 4.2

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 3%
Percent of Short-Stay Residents With Pressure Sores: 17%
Percent of High-Risk Residents Who Have Pressure Sores: 18%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 28%
Percent of Residents Who Have Moderate to Severe Pain: 4%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 8%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 2%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 22%
Percent of Residents Who are More Depressed or Anxious: 14%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 1%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 53%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 9%
Percent of Residents With a Urinary Tract Infection: 8%
** Details Last Reported on: 4/3/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-02-15	2001-03-27	Resident Rights Deficiencies	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Rights Deficiencies	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Pattern	Potential for minimal harm
2001-02-15	2001-03-27	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Environmental Deficiencies	Keep temperature levels comfortable and safe.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Quality Care Deficiencies	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Isolated	Actual harm
2001-02-15	2001-03-27	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Pharmacy Service Deficiencies	Provide drugs and related services needed by each resident.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
2001-02-15	2001-03-27	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Resident Rights Deficiencies	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Pharmacy Service Deficiencies	Provide drugs and related services needed by each resident.	Isolated	Minimal harm or potential for actual harm
2002-04-05	2002-05-23	Administration Deficiencies	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Resident Rights Deficiencies	Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Environmental Deficiencies	Keep temperature levels comfortable and safe.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Quality Care Deficiencies	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Nutrition and Dietary Deficiencies	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
2003-04-03	2003-05-15	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm

*** All violations listed are based on federal government records.