Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tiffany Heights during CMS and state inspections, most recent first.
Three residents in the facility were found with medications left unattended at their bedside without proper assessments for self-administration. One resident, with multiple health conditions, had medications like Biofreeze and cough drops without a care plan. Another resident, with dementia and Parkinson's, had eye drops and nasal spray without physician orders. A third resident, with Parkinson's, had pills and nasal spray left by staff without a documented assessment. The facility's lack of oversight and adherence to medication management policies led to this deficiency.
The facility failed to address grievances and recommendations from the resident council, affecting eight residents and potentially others. Residents were unaware of grievance procedures and did not receive formal feedback. The facility did not document responses to council concerns, and meetings lacked a council president. The Activity Director confirmed the feedback process was informal and untracked.
The facility failed to obtain signatures from two residents or their legal representatives on the NOMNC and SNF ABN forms before discharging them from Medicare services. Despite contacting the residents' durable power of attorney by phone and mail, the necessary signatures were not secured, as required by the form instructions.
The facility failed to maintain privacy for three residents by not posting signage for 24-hour camera surveillance and not obtaining consents. Baby monitors with audio were used without proper consent or signage. Residents involved had cognitive impairments and required assistance with daily activities. The DON stated that signs were unnecessary as cameras were not recording.
The facility failed to include residents' code status wishes in their care plans, affecting five residents. Despite having documented DNR orders, the care plans did not reflect these critical directives. Interviews with staff confirmed the expectation that care plans should address code status, yet this was not implemented.
The facility failed to develop comprehensive care plans for six residents, omitting critical elements such as code status, fall risk interventions, and side rail assessments. Residents experienced multiple falls, and care plans were not updated with new interventions. Staff showed a lack of understanding regarding care plan updates and side rail assessments.
The facility failed to follow professional standards of care, affecting several residents. A resident had side rails installed without a physician's order, while another did not receive prescribed medications consistently. Medications were found at a resident's bedside without orders, and an immobilizer was not worn as required. Additionally, there were blanks in the MAR without annotations. These issues highlight lapses in medication management, safety protocols, and documentation practices.
The facility failed to provide individualized activity programs for two residents, as required by their care plans. One resident, with cognitive impairments and depression, had no documented activity participation despite a goal of two activities daily. Another resident, with Alzheimer's and depression, did not receive preferred activities like pet therapy due to scheduling issues. The Activities Director noted challenges in engaging residents and limited availability of pet therapy.
The facility failed to conduct and document monthly drug regimen reviews for residents, as required by their policies. This affected several residents who were on various medications, including antidepressants and antipsychotics. The facility did not obtain signed statements from the pharmacist when no irregularities were found, and there was no documentation of reviews being completed or provided to physicians.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN did not provide proper instructions for nasal spray administration to a resident, and another resident received an incorrect dosage of eye drops. The LPN was unaware of the lacrimal pressure technique, and the DON confirmed the need to follow manufacturer's guidelines.
The facility failed to ensure food was served at safe and appetizing temperatures, with items held on the steam line for excessive periods without temperature checks. Residents reported dissatisfaction with food quality and temperature, and facility policies lacked guidance on food safety standards.
The facility failed to implement enhanced barrier precautions for two residents with wounds and catheters, lacking necessary signage and PPE. Additionally, clean laundry was transported uncovered, and staff were not adequately trained on infection control measures.
A resident with an indwelling catheter did not receive proper catheter care, as observed in a facility. Staff failed to separate and clean all skin folds and used the same area of a wipe for different areas, contrary to policy. The catheter tubing was also not cleaned. Interviews confirmed the staff's acknowledgment of these errors.
The facility did not follow its medication storage policy by keeping food items like applesauce and Med Pass in the medication refrigerator, which should have been used exclusively for medications. An LPN confirmed the use of these items for medication pass, and the DON stated that such storage was permissible if separated from medications, contrary to the facility's policy.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that three residents were assessed for the safety of self-administering medications, leading to medications being left unattended at their bedside. Resident #6, who was cognitively intact and had multiple diagnoses including high blood pressure and diabetes, had medications such as Biofreeze, cough drops, and vapor rub at their bedside without a proper assessment or care plan for self-administration. The resident stated they did not self-administer medications, yet used Biofreeze for pain relief, indicating a lack of oversight and adherence to the facility's policy. Resident #34, also cognitively intact but with conditions such as dementia and Parkinson's disease, had various medications including eye drops and nasal spray at their bedside without any physician orders or assessments for self-administration. Interviews with the Director of Nursing and an LPN revealed a lack of awareness and documentation regarding residents' ability to self-administer medications, highlighting a systemic issue in the facility's medication management practices. Resident #31, who had no cognitive deficits and was diagnosed with Parkinson's disease, had medications left at their bedside, including a medicine cup with pills and nasal spray, without a documented assessment or care plan for self-administration. The resident indicated that staff left the medications for them to take, and the Director of Nursing confirmed the lack of completed assessments for self-administration. This oversight in medication management and assessment procedures contributed to the deficiency identified by the surveyors.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not considering the views of the resident council and not acting promptly upon grievances and recommendations made by the group. The facility did not demonstrate their response or provide a rationale for such responses to the grievances and recommendations. Additionally, the facility failed to maintain documentation of attempts to resolve concerns or communicate follow-up actions to the council. This affected all eight residents serving on the resident council and potentially other residents in the facility, which had a census of 37. During interviews, residents reported not having access to grievance forms or knowledge of the Council Response Form for receiving feedback on grievances. They were also unaware of who the Grievance Officer was and did not receive formal feedback on their grievances. The review of resident council minutes from June to August 2024 showed no facility responses to past complaints or requests, and meetings were led by the Activity Director without a council president. The Activity Director confirmed that the facility did not formally reply to the resident council on resolutions or steps taken to address issues, and the feedback process was informal and not tracked.
Failure to Obtain Required Signatures on Medicare Notices
Penalty
Summary
The facility failed to obtain signatures from residents or their legal representatives on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms before discharging two residents from Medicare services. This deficiency was identified for two out of three sampled residents, with the facility census being 37. The NOMNC and SNF ABN forms require a signature from the beneficiary or their authorized representative to acknowledge that they have read and understood the notice. The facility did not secure these signatures for Resident #23 and Resident #13, despite making phone calls and sending letters to their durable power of attorney. For Resident #23, the facility documented a phone call and mailed a letter to the resident's durable power of attorney on the same day, two days before the resident was discharged from skilled Medicare services. Similarly, for Resident #13, the facility documented a phone call and mailed a letter to the resident's durable power of attorney five days before the discharge. However, in both cases, the facility did not obtain the necessary signatures on the NOMNC and SNF ABN forms, as required by the form instructions. During an interview, the Administrator acknowledged the expectation that beneficiary notices should be signed by the responsible party.
Privacy Breach Due to Unconsented Camera Surveillance
Penalty
Summary
The facility failed to maintain the privacy of three residents by not posting signage indicating 24-hour camera surveillance and not obtaining consents from responsible parties. The facility's policy on videotaping and photographing residents did not address the use of camera surveillance or the need for consents. Observations revealed that baby monitors with audio capabilities were used in residents' rooms without proper signage or consent. Resident #10 had a care plan indicating a camera was in the room to monitor for falls, but there was no consent for 24-hour surveillance. The resident had cognitive impairment and required assistance with daily activities. A baby monitor was observed in the room, and a monitor at the nurse's station displayed the resident's room with audio capabilities. Resident #32's care plan did not address the roommate's camera surveillance, and there was no consent from the responsible party. The resident had severe cognitive impairment and required assistance with daily activities. Similarly, Resident #17's care plan did not indicate surveillance, and there was no consent for video monitoring. The resident was severely cognitively impaired and dependent on staff for care. The Director of Nursing stated that no signs were needed as the cameras were not recording, and the family had requested them.
Failure to Address Code Status in Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for five residents, specifically neglecting to address their code status wishes. This deficiency was identified through observation, interviews, and record reviews. The facility's policy mandates that care plans should include measurable objectives and timetables to meet residents' needs, developed by an interdisciplinary team in conjunction with the resident and their family or legal representative. However, the care plans for five residents did not reflect their expressed wishes regarding do not resuscitate (DNR) orders, despite these being documented in the facility's code status book and physician's orders. For instance, Resident #18 had a signed out-of-hospital DNR sheet, but their care plan did not address this code status. Similarly, Resident #34 and Resident #6 had DNR orders documented, but their care plans failed to include this critical information. Interviews with facility staff, including an LPN and the MDS Coordinator, confirmed that care plans should address residents' code status. The Administrator acknowledged that care plans should be updated with significant changes and that code status is reviewed at every care plan meeting, yet the deficiency persisted.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for six residents, which did not align with the residents' medical, nursing, mental, and psychosocial needs. For Resident #7, the care plan did not include the resident's code status wishes, despite having a DNR order. Similarly, Resident #27's care plan omitted the code status and did not address the resident's high risk for falls, even though the resident had a history of falls and a high fall risk score. Resident #17's care plan lacked interventions for the 24-hour video and audio surveillance in the resident's room, which was observed at the nurse's station. Resident #6's care plan did not address the use of side rails, despite the resident using them for assistance at night. The assessments showed inconsistencies in the indication for side rails, with the resident expressing a desire for them to promote independence. Resident #18's care plan did not include any assessments for side rails, although they were observed in use. Resident #34's care plan did not include new fall interventions after multiple falls, and side rails were not care planned despite being used to hold the call light. The facility's staff, including the DON and LPN, demonstrated a lack of understanding regarding the necessity of updating care plans with significant changes and the inclusion of side rail assessments.
Deficiencies in Medication Management and Resident Safety Protocols
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, affecting multiple residents. For Resident #18, side rails were installed without a physician's order, despite the previous discontinuation of such an order. Observations confirmed the presence of side rails, and the Director of Nursing was unaware of the requirement for physician orders for bed rails. This oversight indicates a lack of compliance with established protocols for resident safety and care. Resident #31 did not receive prescribed medications consistently, with Pataday Ophthalmic Solution not administered for 27 days and Polyethylene Glycol given only 12 times out of 27 days. The resident reported not receiving eye drops for months, and staff confirmed the medication was out of stock without being reordered. This failure to provide necessary medication as per physician orders highlights a significant lapse in medication management and inventory control. For Resident #34, there was no assessment for self-administration of medications, yet multiple medications were found at the bedside without orders. Additionally, the resident was observed without an immobilizer, contrary to physician orders. The facility's documentation practices were also deficient, as evidenced by blanks in the Medication Administration Record (MAR) for Resident #6, with no annotations explaining the omissions. These deficiencies collectively demonstrate a failure to maintain accurate records and ensure adherence to prescribed care plans.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide an ongoing activity program that supports residents in their choice of activities, affecting two residents out of a sample of 12. The facility's policies require activities to be scheduled seven days a week and tailored to individual needs, with records maintained for attendance and participation. However, the facility did not document any activities for Residents #12 and #29 over the last 90 days, indicating a lack of adherence to these policies. Resident #12, with moderately impaired cognitive skills and multiple health conditions including depression, had no documented activity participation despite a care plan goal of engaging in two activities daily. The resident's care plan included encouragement to participate in group activities and independent activities like reading mail and sitting outside. However, there was no evidence of these activities being offered or documented, and the Activities Director noted difficulty in engaging the resident due to frequent sleeping. Resident #29, with severely impaired cognitive skills and several health conditions including Alzheimer's and depression, also had no documented activity participation. The resident's care plan emphasized the importance of pet therapy and family visits, yet these preferences were not met, with pet therapy occurring infrequently due to scheduling issues. The Activities Director acknowledged the limited availability of pet therapy and could not recall the last session, highlighting a gap in meeting the resident's individual activity preferences.
Failure to Conduct and Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for residents, as required by their policies and procedures. Specifically, the facility did not obtain a signed and dated statement from the pharmacist when no irregularities were identified during the medication regimen review. Additionally, the pharmacist's date of review and name were not listed on any medication regimen reviews. This deficiency affected five of the twelve sampled residents, and there was no documentation that a monthly medication regimen review was completed or provided to the physician. For Resident #6, the facility's records showed that there were no drug regimen reviews conducted from April to July 2024. The resident was on several medications, including an antidepressant, anticoagulant, and diuretic, and had a history of high blood pressure, heart failure, diabetes, depression, asthma, neuropathy, and generalized muscle weakness. Despite the absence of documented reviews, progress notes indicated that pharmacy consults were received with no irregularities noted in previous months. Similarly, for Resident #18, there were no documented drug regimen reviews from April to July 2024. The resident was on antipsychotic, anticoagulant, and diuretic medications, with diagnoses including dementia, anxiety disorder, and depression. The facility's records showed that gradual dose reductions were attempted, but there was no documentation of the pharmacist's review or physician's acknowledgment. The lack of proper documentation and communication between the pharmacist and the physician contributed to the facility's failure to comply with its medication regimen review policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 8% due to two medication errors out of 25 opportunities. This affected two residents. One resident was observed self-administering Flonase nasal spray without proper instructions from the LPN, who did not instruct the resident to close one side of the nostril as per the manufacturer's guidelines. The LPN admitted to not providing instructions and only following the physician's orders, while the Director of Nursing acknowledged that staff should follow the manufacturer's guidelines unless otherwise directed. Another resident received an incorrect dosage of Systane eye drops, with the LPN administering two drops in each eye instead of the ordered one drop. Additionally, the LPN did not apply lacrimal pressure, a technique not known to the LPN or the Director of Nursing. The Director of Nursing confirmed that staff should administer the correct amount of eye drops as ordered and was unaware of the lacrimal pressure technique.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations revealed that cooked foods were not temperature checked and were held on the steam line for excessive periods, with spinach and au gratin potatoes warming for three hours and the main course ham for two hours. No temperatures were taken for any items on the steam line before or during serving, and banana pudding was served without temperature checks to ensure it was below 41 degrees. Interviews with residents indicated dissatisfaction with the food quality and temperature. One resident, who was cognitively intact, reported that while food temperatures were appropriate, the taste was unsatisfactory. Another resident with significant cognitive impairment mentioned that food was sometimes cold, and vegetables were inconsistently cooked. A resident's responsible party also noted that the food was often cold and unpalatable. The facility's policies lacked guidance on food safety standards, and there was no policy on required temperature checks of cooked food. The Dietary Manager and Administrator both expressed expectations that food should not be on the steam line for more than two hours and that temperature checks should be conducted according to facility policy. However, these expectations were not met, leading to the deficiency in food service quality.
Inadequate Infection Control Measures for Residents with Wounds and Catheters
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of enhanced barrier precautions (EBP) for residents with open wounds and catheters. Resident #18, who had a stage 3 pressure ulcer and was dependent on a wheelchair for mobility, did not have EBP signage or personal protective equipment (PPE) in or outside their room. Despite having a care plan that required specific wound care, observations over several days confirmed the absence of necessary precautions. Similarly, Resident #17, who was severely cognitively impaired and had an indwelling urinary catheter, also lacked EBP signage and PPE. The resident required substantial assistance for daily activities and had multiple diagnoses, including cancer and dementia. Observations during room visits confirmed that no enhanced barrier precautions were in place for this resident. Additionally, the facility did not have a policy for the transportation of clean laundry, leading to uncovered laundry being transported throughout the facility. Interviews with staff, including the Laundry Aide and LPN, revealed a lack of understanding and training regarding EBP. The Infection Preventionist and Administrator acknowledged the absence of precautions and signage, citing issues with ordering and implementing necessary materials.
Improper Catheter Care Leading to Potential UTI Risk
Penalty
Summary
The facility failed to provide proper catheter care to prevent urinary tract infections for a resident with an indwelling catheter. The resident, who had obstructive uropathy and was dependent on staff for all toileting needs, was observed receiving inadequate catheter care. During the care, a Certified Nurse Aide (CNA) and a Nurse Aide (NA) did not separate and clean all areas of the resident's skin folds properly and used the same area of a wipe to clean different areas, which is against the facility's policy. Additionally, the catheter tubing was not cleaned during the process. Interviews with the involved staff confirmed the improper cleaning techniques used during the catheter care. Both the CNA and NA acknowledged that they should have separated and cleaned all skin folds and used a different area of the wipe for each area of the skin. They also admitted that the catheter tubing should have been cleaned. The Director of Nursing reiterated that the staff should follow the correct procedure of one wipe, one swipe, and ensure all skin folds and catheter tubing are cleaned properly.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its medication storage policy by storing food items alongside medications in the medication refrigerator. During an observation and interview, it was noted that the refrigerator contained at least 15 containers of applesauce, nine containers of Med Pass (an oral nutritional supplement), and two small containers of tomato juice, which were reportedly used for medication pass. The facility's policy mandates that medications requiring refrigeration must be stored separately from food and labeled accordingly. However, the Director of Nursing indicated that these food items could be stored in the refrigerator as long as they were separated from the medication, which contradicts the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mound City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oregon Care Center | 12.1 mi | — | 9 | 0 |
| Falls City Nursing And Rehabilitation Center | 19.7 mi | — | 0 | 0 |
| Nodaway Healthcare | 20 mi | — | 2 | 0 |
| Falls City Care Center | 20.4 mi | — | 0 | 0 |
| Parkdale Manor Health & Rehabilitation | 22.5 mi | — | 1 | 0 |
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