Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tiffany Square during CMS and state inspections, most recent first.
A resident with acute on chronic diastolic CHF and on warfarin therapy had a urinalysis that resulted in physician orders to start Macrobid and reduce the warfarin dose by half, but these orders were not implemented. Subsequent documentation showed warfarin dose changes based on INR results, initiation of Paxlovid for COVID without documented pharmacy review of the warfarin–ritonavir interaction, and delayed follow-up on the original urinalysis order. The resident later exhibited nosebleeds, dizziness, lightheadedness, nausea, emesis, and low tympanic temperature, leading to transfer to the ER. The DON reported there was no specific policy for taking or following physician orders and could not explain why the antibiotic order for the positive UTI was not initiated.
Failure to Follow Bowel Protocol and Document Constipation Care The facility did not consistently follow or document its bowel elimination protocol for residents with ongoing constipation. A resident with chronic pain and multiple constipation-causing medications had repeated requests for laxatives, but the chart lacked bowel sound assessments, abdominal palpation findings, and physician notification when constipation persisted. Two other residents also had repeated days without bowel movements, yet constipation was not consistently reflected in the care plan or documented bowel interventions, and the DON confirmed the protocol was not being followed as required.
Hand hygiene was not performed before glove use during resident care, including when an aide provided Foley catheter care for one resident and when an RN performed a fingerstick on another resident. A resident with an indwelling Foley catheter was also repeatedly observed with the drainage bag hanging on a trash can or sitting on the floor, and the IP nurse acknowledged this was an infection control risk.
Failure to monitor psychotropic and antipsychotic medications: Two residents received psychoactive meds, including antipsychotics, without required AIMS assessments and without documented behavior or side-effect monitoring. One resident also had incomplete consent forms and PRN orders for Xanax and Ambien without documented rationale or duration, while the other resident had no current AIMS during the stay despite ongoing Rexulti use.
The facility failed to follow physician orders for wound care for two residents and did not obtain necessary orders for another. A resident received incorrect wound cleansing, while another had medication applied improperly. Additionally, a resident returned with a pressure ulcer but lacked treatment orders. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to implement Enhanced Barrier Precautions for a resident with hemiplegia during transfers, as staff did not wear gowns or clean the lift between uses. Additionally, improper wound care was provided to another resident with a pressure ulcer, risking cross-contamination. The DON confirmed these deficiencies, acknowledging non-compliance with infection control policies.
The facility failed to manage psychotropic medications appropriately for three residents. Two residents received antidepressants without documented mood or behavior changes, and their care plans lacked specific behaviors for medication use. Additionally, informed consent for one resident's medication was unsigned. Another resident had a PRN psychotropic medication without an end date, and the DON was unaware of this oversight.
The facility failed to serve the correct portion size of beef chili to 50 residents, using a 6-ounce ladle instead of the required 8-ounce portion as per the menu. This discrepancy was confirmed by the dietary staff and the RD, despite the facility's audit indicating that portions should follow the menu specifications.
The facility failed to ensure proper hand hygiene by a staff member delivering laundry, who did not sanitize hands between resident rooms, and did not maintain oxygen equipment per infection control procedures for a resident with COPD. The nasal cannula for the resident's portable oxygen container had not been changed since August, contrary to monthly requirements.
A facility failed to document a recapitulation of a resident's stay as required. The resident, who aimed to return home with their spouse, was involved in discharge planning discussions. However, the medical record lacked a documented summary of the stay. The DON confirmed the absence of a Nursing Discharge Summary and acknowledged the facility's lack of a discharge policy.
A survey revealed a 12% medication error rate in a facility, affecting three residents. Errors included improper administration of Potassium Chloride tablets without a full glass of water for two residents and incorrect inhaler use for another resident, with no waiting period between puffs. These errors were confirmed by the MA-C and DON.
A facility failed to ensure proper labeling of medications, leading to discrepancies between medication labels and physician orders for a resident. An RN identified that the label on a box of Insulin Aspart did not match the physician's order, and a vial of Lantus insulin was mislabeled with an incorrect discard date. The DON confirmed these discrepancies and acknowledged the need for accurate labeling as per facility policy.
Failure to Follow Physician Orders for Anticoagulation and UTI Treatment
Penalty
Summary
Surveyors identified a failure to follow practitioner orders for a resident admitted with acute on chronic diastolic congestive heart failure. The resident’s care plan included interventions to administer medications per MD order and to consult the pharmacist for monthly and PRN medication reviews, including medications with black box warnings. On admission, a future lab order was entered for an INR draw, and on 2/13 a urinalysis was ordered. The hospital lab urinalysis collected on 2/13 and finalized on 2/15 included physician-directed medication changes: initiation of Macrobid 100 mg PO BID for 7 days and a decrease in the resident’s warfarin dose by half while on the antibiotic, with an electronic physician signature. These medication orders were not implemented as directed. Progress notes showed that an INR was drawn on 2/16 and that staff called the physician’s office on 2/17 for recommendations, but there was no documentation of follow-up on the Macrobid order from the 2/15 urinalysis report. On 2/18, the resident tested positive for COVID and was started on Paxlovid. The order recap showed multiple warfarin dose changes over the subsequent days, including a change from 5 mg daily to 4 mg daily, then to 3 mg daily, and an order for vitamin K after an INR of 7.3 was obtained on 2/23, along with instructions to hold warfarin for two days and recheck the INR. The record also showed a delayed urinalysis order on 2/23, despite the original urinalysis order dated 2/13 and the earlier lab results with treatment recommendations. The resident experienced nosebleeds over a weekend and, on 2/23, was documented as feeling dizzy, lightheaded, nauseated, with two episodes of emesis and a tympanic temperature of 95°F, leading to an order to send the resident to the emergency room. There was no documentation of pharmacy review or communication regarding the interaction between Paxlovid and warfarin, despite reference information advising frequent INR checks and anticoagulant dose adjustments when warfarin is co-administered with ritonavir-containing therapy. In an interview, the DON stated there was no facility policy on taking or following physician orders and that the facility relied on general standards of practice. The DON acknowledged not knowing why the Macrobid order from the 2/15 urinalysis result was not followed and could not explain why the antibiotic for the positive UTI was not initiated per physician orders.
Failure to Follow and Document Bowel Elimination Protocol
Penalty
Summary
The facility failed to re-evaluate and revise bowel interventions for residents with ongoing constipation, and the record showed that the bowel elimination protocol was not consistently followed or documented. The protocol required staff to review bowel records nightly, provide prune juice or another natural laxative on day 2 without a bowel movement, administer ordered PRN laxatives and assess bowel sounds and abdominal findings on day 3, and contact the physician with escalation to an enema on day 4 if no bowel movement occurred. However, the report states that assessments for bowel sounds and abdominal palpation were not documented as required, and the protocol actions were not consistently recorded in the progress notes, TAR, or MAR. Resident 57 had diagnoses including fractured rib, chronic pain, depression, anxiety, osteoporosis, GERD, and malnutrition, and was taking multiple medications associated with constipation, including scheduled and PRN oxycodone, Miralax, Colace, Dulcolax suppository, and MOM. The care plan did not address constipation, despite a bowel assessment identifying the resident as at risk for constipation related to antipsychotic, antidepressant, and opioid use. The MAR showed frequent use of constipation medications, and progress notes documented repeated requests for constipation treatment, but there were no documented bowel sound assessments, abdominal palpation findings, or physician notifications when interventions were ineffective for several days. The DON confirmed that the bowel protocol was not being followed, that assessments were not charted as required, and that the resident’s PRN stool softener was not being used frequently enough. Resident 14 had diagnoses including Lewy body neurocognitive disorder, GERD, diabetes, muscle weakness, major depressive disorder, dementia, and anxiety, and the record showed repeated periods without a bowel movement over several months. Although the resident had PRN orders for Fleet enema, bisacodyl suppository, and polyethylene glycol, along with scheduled Senna S, the care plan did not identify constipation as a problem. Resident 75 had a diagnosis of constipation and a care plan noting potential altered bowel elimination, but the bowel documentation showed days without bowel movements and blank entries where prune juice or other interventions should have been recorded. The MAR did not show prune juice on day 2 or PRN constipation medications on day 3, and the DON confirmed there was no documentation of prune juice or other natural supplements in the progress notes or MAR.
Hand Hygiene and Foley Catheter Infection Control Lapses
Penalty
Summary
Hand hygiene was not performed before glove use during resident care. Facility policy titled Hand Hygiene dated 9/12/17 stated that hand hygiene is to occur before and after patient contact. During observation on 12/3/25, a nurse aide put on a gown and gloves without performing hand hygiene before entering Resident 7’s room. The nurse aide then obtained supplies, approached Resident 7, removed the catheter urine collection bag from the privacy cover, wiped the drain tip with alcohol prep pads, emptied 525 cc of dark yellow urine into a graduate, and returned the drain to the holder. The nurse aide later confirmed that hand hygiene is to be completed prior to putting on gown and gloves. A similar hand hygiene lapse was observed on 12/4/25 when a registered nurse administered oral medications to Resident 19 and then used a lancet to puncture the resident’s finger for blood sugar testing while wearing gloves, without performing hand hygiene before putting on the gloves. The nurse removed the gloves and repositioned a pillow that had fallen on the floor, then exited the room and performed hand hygiene. In addition, Resident 42, who had a diagnosis of neuromuscular dysfunction of the bladder and a care plan identifying infection risk related to an indwelling Foley catheter, was repeatedly observed with the catheter bag hanging on a trash can containing trash or sitting on the floor next to the trash can. The Infection Control and Prevention Nurse acknowledged that staff were hanging catheter bags on trash cans and agreed this was an infection control risk.
Failure to Monitor Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to ensure approved diagnoses and required monitoring for psychotropic medications for two residents. One resident was admitted with diagnoses including depression, insomnia, anxiety disorder, chronic pain, hypertension, and a fractured rib, and was receiving multiple psychoactive medications, including Seroquel, Lexapro, Xanax, Ambien, and melatonin. The resident’s care plan directed staff to monitor for adverse effects such as changes in behavior, slurred speech, disorientation, dizziness, impaired thinking, memory loss, suicidal thoughts, constipation, tremors, and insomnia, among other symptoms. For this resident, the record showed no AIMS assessment on admission or through the survey period, even though the resident was receiving an antipsychotic. The informed consent forms for Seroquel, Lexapro, and Xanax were signed, but the medication names were not listed in the consent section and the forms were incomplete. The physician orders for PRN Ambien and PRN Xanax did not include a documented rationale for continued use, and the consultant pharmacist had requested that rationale and duration be documented. The MARs for September, October, November, and December 2025 contained no documentation related to behaviors or other information required for psychoactive medication monitoring, and progress notes from admission through the survey date contained no entries related to monitoring behaviors or side effects. A second resident had been admitted to the facility and was receiving Rexulti, an antipsychotic medication, with an order that had been renewed during the current stay. The resident’s record showed only one AIMS assessment, completed during a prior stay in 2021, and no AIMS assessments were completed during the current stay or quarterly as required. The consultant pharmacist had recommended updating the chart with a more recent AIMS assessment due to Rexulti use, and the DON confirmed that the resident was taking the antipsychotic medication and that quarterly AIMS assessments should have been completed, but they were not.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide wound care according to physician orders for two residents and did not obtain physician orders for wound care for another resident. Resident 2, who was admitted with hepatic failure, congestive heart failure, and dementia, was observed receiving wound care that did not follow the physician's orders. The Licensed Practical Nurse (LPN) used normal saline instead of soap and water to cleanse the wound, which was contrary to the prescribed treatment plan. This deviation was confirmed by both the LPN and the Director of Nursing (DON). Resident 3, admitted with hemiplegia, type 2 diabetes, and chronic pulmonary disease, was also subject to improper wound care. The Registered Nurse (RN) applied topical antibiotic ointment and viscous lidocaine to the skin surrounding the wound instead of directly to the wound as ordered by the physician. This incorrect application was acknowledged by the RN and confirmed by another LPN and the DON. Resident 1, who had type 2 diabetes and congestive heart failure, returned to the facility with a pressure ulcer on the right buttock. Despite documentation of the wound in progress notes and after-visit summaries, there were no physician orders for treatment of the pressure ulcer. This lack of treatment orders was confirmed by the RN and the DON, indicating a failure to obtain necessary medical directives for wound care management.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for Resident 3, who was admitted with diagnoses including hemiplegia, type 2 diabetes, and chronic pulmonary disease. Despite the facility's policy requiring the use of gowns and gloves during high-contact resident care, Nurse Aide C and Nurse Aide E did not wear gowns while assisting Resident 3 with a transfer using a full body lift. Additionally, the lift was not cleaned between uses, as required by the facility's Mechanical Lift and Transfer Standard policy. Both nurse aides confirmed their failure to adhere to the EBP and lift cleaning protocols during interviews. Resident 2, who was admitted with hepatic failure, congestive heart failure, and dementia, was also subject to deficient care practices. The resident had a pressure ulcer, and the care plan included an order to cleanse the wound with soap and water and apply zinc oxide twice daily. However, during an observation of wound care, LPN-B did not cleanse the wound properly and applied a thick white cream in a manner that could lead to cross-contamination. LPN-B confirmed the improper technique during an interview. The Director of Nursing (DON) confirmed the deficiencies in both cases, acknowledging that the staff failed to follow the facility's infection control policies. The DON verified that Resident 3 required EBP for all direct care, including transfers, and that lifts should be cleansed between each resident use. Similarly, the DON confirmed that the wound care for Resident 2 was not performed in a manner to prevent cross-contamination.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that the medication regimen for two residents was free from unnecessary psychotropic medications. Resident 10, who was admitted with diagnoses of depression and anxiety, had their Lexapro dosage increased without documented evidence of mood or behavior changes that would justify the increase. The facility did not document any specific or targeted behaviors for the use of antidepressant medication in Resident 10's care plan, and there was no evidence of monitoring the resident's mood and behaviors in the weekly risk meetings. Additionally, the Director of Nursing (DON) was unaware of the changes in the resident's antidepressant medication and the lack of documentation to support these changes. Resident 32, diagnosed with Alzheimer's disease and depression, was receiving routine antidepressant medication without a gradual dose reduction or documentation that such a reduction was clinically contraindicated. The care plan for Resident 32 also lacked specific or targeted behaviors for the use of antidepressant medication. Furthermore, the informed consent for the use of psychotropic medications was not signed by the resident or their responsible party, and there was no documentation of mood or behavior changes to support the addition of Zoloft to the resident's medication regimen. The DON confirmed that Resident 32's mood and behaviors were not being monitored in the weekly risk meetings. The facility also failed to implement a stop date for a PRN psychotropic medication for Resident 12, who was admitted with a terminal prognosis related to atrial fibrillation. The resident's care plan included a focus on maintaining comfort levels, but the order for Lorazepam, a psychotropic medication prescribed as needed, did not have an end date. The DON and Administrator were initially unaware of the lack of an end date for the PRN medication, which was later confirmed during the survey.
Deficiency in Serving Correct Food Portion Sizes
Penalty
Summary
The facility failed to ensure that residents were served the required food portion size per the menu to meet nutritional needs for 50 out of 58 residents. The facility's menu specified that the regular portion size for beef chili was 8 ounces. However, during an observation in the facility kitchen, it was noted that a 6-ounce ladle was used to serve the beef chili instead of the required 8-ounce portion. This discrepancy was confirmed by Dietary Cook-A and the Registered Dietitian (RD), who acknowledged that the residents did not receive the 8-ounce serving as required by the menu. The facility's Food Preparation and Dining Service Audit indicated that standardized recipes were available and portions were to be served according to the menu unless otherwise requested by the resident. Despite this, the serving utensils used did not align with the menu specifications, leading to the deficiency. Additionally, a list provided by the facility's RD showed that 15 residents had requested small portions, but this did not account for the 50 residents who were affected by the incorrect portion size of the beef chili.
Infection Control Deficiencies in Hand Hygiene and Oxygen Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by the Laundry and Housekeeping Supervisor (LHS) while delivering laundry to resident rooms. On multiple occasions, the LHS was observed handling clean laundry and potentially contaminated hangers without performing hand sanitization between resident rooms. The LHS did not use alcohol-based hand sanitizer or wash hands with soap and water, despite acknowledging that all employees are expected to do so to prevent cross-contamination and reduce infection risks. Additionally, there was no alcohol-based hand sanitizer available on the laundry cart used by the LHS. The facility also failed to maintain oxygen equipment and supplies according to infection control procedures for a resident with chronic diastolic heart failure and chronic obstructive pulmonary disease (COPD). The resident's care plan required oxygen therapy, and orders were in place for changing oxygen tubing and holders monthly. However, observations revealed that the nasal cannula connected to the portable oxygen container had not been changed since 08/02, indicating non-compliance with the infection control procedures. The Director of Nursing confirmed that the nasal cannula should be changed monthly and tagged with a date and initials. These deficiencies highlight lapses in the facility's infection prevention and control program, specifically in hand hygiene practices and the maintenance of medical equipment. The lack of adherence to established protocols for hand hygiene and equipment maintenance poses a risk of cross-contamination and infection among residents.
Failure to Document Recapitulation of Resident's Stay
Penalty
Summary
The facility failed to ensure that a recapitulation of a resident's stay was completed as required for a resident who was reviewed. The resident, identified as Resident 78, was admitted to the facility and had a goal to return home with their spouse. The Minimum Data Set (MDS) assessments indicated that the resident and their spouse were involved in the assessment and goal-setting process, with the overall goal being to discharge to the community. Progress notes documented ongoing discussions about discharge plans between the resident, their spouse, and the facility. However, upon review of the medical record, it was found that there was no documented recapitulation of the resident's stay. An interview with the Director of Nursing (DON) revealed that the facility lacked a policy or procedure for resident discharge and relied on a Nursing Discharge Summary assessment to document the recapitulation of stay. The DON confirmed that this summary was not completed for the resident, resulting in the deficiency.
Medication Administration Errors Observed
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 12% during a survey. This deficiency affected three of the eleven sampled residents. The errors were identified during the observation of medication administration by a Medication Aide (MA-C). For Resident 13, the MA-C did not ensure the resident drank a full glass of water with their Potassium Chloride Extended Release tablet, as required by the medication's administration instructions. Similarly, Resident 30 was not provided with a full glass of water for their Potassium Chloride tablets, contrary to the prescribed directions. Additionally, Resident 33's inhaler administration was not conducted according to the prescribed method. The resident was instructed to inhale two puffs of medication with a one-minute interval between puffs, but the MA-C allowed the resident to take both puffs consecutively without the required waiting period. These actions were confirmed as medication errors by both the MA-C and the Director of Nursing (DON) during interviews conducted as part of the survey process.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medications for a resident, leading to discrepancies between medication labels and physician orders. During an observation of insulin administration, a Registered Nurse (RN) identified that the label on a box of Insulin Aspart did not match the physician's order in the electronic medical health record. The label provided a simplified version of the sliding scale instructions, which did not align with the detailed physician order. The RN acknowledged that medication should not be administered if the label and order do not match, indicating a need for clarification before administering the medication. Additionally, the RN discovered a mislabeling issue with a vial of Lantus insulin. The discard date on the vial was incorrectly labeled as 10/29, instead of the correct date of 10/26, which is 28 days from the opening date of 09/29. The Director of Nursing (DON) confirmed these discrepancies and acknowledged that the facility's policy was to use 'use as directed' on labels for complex instructions. The DON also confirmed that the discard date should be accurately calculated and labeled as per the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Grand Island Village | 0.2 mi | ★★★★★ | 16 | 0 |
| Chi Health St. Francis | 0.6 mi | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of Grand Island | 0.6 mi | ★★★★★ | 0 | 0 |
| Eventide Prairie Commons Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Lakeview | 2.8 mi | ★★★★★ | 19 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Tiffany Square.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.