Tipton Oak Manor

Inspectors wroteBased on interviews and record reviews, facility staff failed to initiate and complete a thorough investigation of a missing Fentanyl patch (an opioid medication to treat pain) for two residents (Resident #4 and Resident #8) of two sampled residents. The facility census was 53.1. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property, undated, showed all allegations of misappropriation of resident property will be reported immediately but no later than the following timeframes. If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24 hours after the allegation was made. [...]

Inspectors wroteBased on record review and interview, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The census was 53.1. Review of the facility's policies showed staff did not provide a policy that directed staff on the requirements for RN coverage. Review of the facility's Facility Assessment Tool, dated 2/27/26, showed the Facility Assessment Tool did not direct staff on RN coverage seven days a week for eight consecutive hours. Review of the facility staff schedule, dated December 2025, showed the facility did not have an RN for eight consecutive hours on 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure the two-step purified protein derivative (PPD), a skin test for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) was completed and on file in accordance with the facility policy for five employees (Dietary Aide (DA) C, Certified Medication Technician (CMT) D, Licensed Practical Nurse (LPN) F, Laundry Aide G, and Certified Nurse Aide (CNA) H out of eight employee files reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one resident's (Resident #37) of two sampled residents. The census was 53. 1. Review of the facility's Wound Care and Treatment policy, undated, showed staff were directed as follows: -Washing hands must be done as outlined in the guidelines; -Wash your hands and put on gloves; -Clean the wound according to the order; -Remove gloves, place in trash bag, and put on a clean pair of gloves; -Position resident comfortably with call light in reach; -Wash your hands. Review of the facility's policy titled, Handwashing, undated, showed the policy did not direct staff on when to wash hands. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner when staff failed to date and label insulin pens (to treat high blood sugar). The facility census was 47. 1. Review of the facility's Labeling Drugs and Medication policy, undated, shows facility staff were directed as follows: -All drugs and biologicals must be properly labeled and legible at all times; -Labels must be permanently affixed to each container; -Medications in container having no labels must be destroyed in accordance with the facility procedures governing the destruction of medications; -Labels for individual drug containers must contain: Resident's full name and room number, expiration date (when applicable), and other appropriate information; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during wound care for one resident (Resident #14), during medication administration for one resident (Resident #4) and failed to implement the enhanced barrier precautions (EBP) (an infection control intervention) policy developed and educate staff who required EBP and place appropriate personal protective equipment (PPE) in close proximity for two out of four sampled residents, one resident (Resident #14) with a wound and one of one resident (Resident #4) with an indwelling gastrostomy tube ((g-tube) surgically placed tube that enters the stomach to deliver fluids and nutrition, that required EBP). The facility census was 47. 1. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to update care plans in regards to smoking for three (Resident #1, #11, and #13) out of six sampled residents. The facility census was 70. 1. Review of the facility's Care Plan Comprehensive Policy, undated, showed assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. Review staff were directed to: -Apply current standards of practice in the care plan process; -Update care plans when a significant change in condition has occurred, at least quarterly, and when changes occur that impact the resident's care. 2. Review of the Resident #1's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as follows: -Cognitively intact; -Tobacco use, not assessed. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of care, when they failed to check placement of a Gastrostomy Tube ((G-Tube) a tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) prior to administration of G-tube feeding, and failed to follow the physician's orders regarding water flushes for one (Resident #4) of one sampled resident with a G-tube. The facility census was 47. 1. Review of the facility's policy for Medication, Administration by Naso-Gastric or Gastrostomy Tube, undated, showed staff are directed: -Wash hands; -Verify the recipient with physician orders and medication administration record; -Check for tube placement; -Give medications only by gravity. Never force with plunger; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete or post required nurse staffing information, which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, on a daily basis in an area readily accessible to residents and visitors. The facility census was 70. 1. Review of the facility's policies showed staff did not provide a policy for the daily nurse staff posting. 2. Observations on 07/29/24 at 2:00 P.M., showed the facility staff did not post the nurse staffing information. Observation on 07/30/24 at 10:00 A.M., showed the facility staff did not post the nurse staffing information. Observation on 07/31/24 11:00 A.M., showed the facility staff did not post the nurse staffing information. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to respect the privacy of two residents (Resident #14 and #4) out of four sampled residents, when staff failed to provide privacy during wound care and medication administration, and posted care signs for on a wall visible to other residents and visitors in the day room. The facility census was 47. 1. Review of the facility's Patient [NAME] of Rights, undated, showed residents shall be treated with consideration, respect and full recognition of your dignity and individuality, including privacy in treatment and in care for your personal needs. 2. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/14/24, showed staff assessed the resident with severe cognitive impairment, and received application of non-surgical dressings other than to feet. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff also failed to clean and sanitize soiled utensils between uses to prevent cross-contamination. The facility census was 47. 1. Review of the facility's Glove Use policy, dated May 2015, showed the policy directed staff to remove their gloves and wash their hands when they change or walk away from a specific task. Review also showed the policy directed staff to wash their hands after they dispose of trash or food, after handling dirty dishes, after they pick up anything from the floor, when they change tasks, and any other time deemed necessary. Observation on 03/09/23 from 7:00 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. The facility census was 47. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observations from 3/6/23 at 10:00 A.M. through 3/9/23 at 8:49 A.M., showed the 100 hall floor with black marks, dirty and with cracked flooring. Further observation showed the walls with black and brown marks. 2. Observation on 3/6/23 at 10:49 A.M., showed Resident #51's room had a dirty, scratched, cracked and stained floor. Further observation showed the walls with black marks, chipped paint and gouges. Observation on 3/7/23 at 9:52 A.M., showed the room had a dirty, scratched, cracked and stained floor. [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to ensure a comprehensive plan of care was developed and implemented for four residents (Resident #3, #9, #34, and #44). The facility census was 47. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed ensure three dependent residents (Resident #12, #14, and #51) received the necessary care and services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair and nails, and failed to ensure residents wore clean clothes. The facility census was 47. 1. Review of the facility's Activities of Daily Living (ADL) policy, dated March 2015, showed: -The purpose is to assist the resident in achieving maximum function; Review showed it did not contain direction for staff in regard to shaving, nail care and ensuring residents wear clean clothing. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/6/23, showed staff assessed the resident as: -Severe Cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekends. Additionally, staff failed to invite dependent residents to activities. The facility census was 47. 1. Review of the facility's Role of the Activity Director, dated March 2012, showed: -The activity director provides a key role in enhancing the quality of a resident's daily life. The activity director plans and promotes meaningful activities based on the resident's interest and desires to provide a more homelike atmosphere in the facility; -Make morning visits to all residents; -Schedule activities that will involve as many residents as possible. Review showed it did not contain direction in regard to weekend activities. 2. Observation from 3/6/23 at 10:00 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel three residents (Resident's #14, #37, #53) in wheelchairs and failed to use a gait belt and the required number of staff when transferring two residents (Resident #21 and #43). The facility census was 47. 1. Review of the facility's Wheelchair Use Of policy, dated March 2015, showed: -The purpose is to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Lower footrests and place resident's feet on footrests if used; -Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a correct count of controlled medications stored in the facility. The facility census was 47. 1. Review of the facility's Narcotic Count Policy, date March 2012, showed: -Staff are to complete a physical inventory of narcotics at each shift change to identify discrepancies; -One Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift; -Narcotic records are reconciled by a physical count of remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse, and the record retained for at least one year; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain proper documentation, assessment, and monitoring for the use of a physical restraint for one resident(Resident #43), who had been placed in chairs that prevented the resident from rising and ambulating. The facility census was 47. 1. Review of the facility's Use of Restraints Policy, dated March of 2012, showed: -Physical restraints are defined as any manual method or physical or mechanical device, material equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; -If the resident cannot remove a device in the same manner as staff applied it, given the resident's physical condition and this restricts his/her typical ability to change position or place, the device is considered a restraint; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain physician orders for the use of Continuous positive airway pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, for one resident (Resident #9). Additionally, staff failed to develop and implement a person centered comprehensive care plan for the resident's use of CPAP. The facility census was 47. 1. Review of the facility's CPAP Administration policy, dated March 2015, showed: -Contact Quality Assurance Nurse prior to placement for clarification of orders and support; -Check physician orders for pressure setting and method of administration; -Assist resident as needed with applying and adjusting CPAP mask and head strap. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure two residents (Resident #2 and Resident #43) had an appropriate indication for the use of antipsychotic medications (used to treat psychosis). The facility census was 47. 1. Review of the facility's Antipsychotic Medication Use Policy, dated March 2015, showed: -Residents will only receive antipsychotic medications when necessary to treat a specific conditions for which they are indicated and effective; -Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions); -Schizo-affective disorder; -Mood Disorders; -Depression with psychotic features, and treatment refractory major depression; -Psychosis, Not otherwise specified (NOS); [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, address, phone numbers of the State Survey Agency (SA) and the name, address and phone number for the for the Long-Term Ombudsman in an accessible location for residents and visitors to view. The census was 47. 1. Review of the policies provided by the facility showed they did not contain a policy for the required postings. Observation from 3/6/23 at 9:00 A.M., through 3/9/23 at 5:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Elder Abuse Hotline or the name, address, and phone number for the Long-Term Care Ombudsman in an accessible location on each unit for residents or visitors to use if needed. [...]