Inspection Reports for The Waters of Tipton Skilled Nursing Facility
300 FAIRGROUNDS RD, IN, 46072
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 16, 2025, identified deficiencies related to failure to notify a physician of a resident injury and failure to ensure resident safety during transfer. Earlier inspections showed a pattern of deficiencies involving emergency preparedness, life safety code compliance, resident care including supervision and assistance, medication management, and infection control. Several complaint investigations were substantiated, including cases involving resident falls, delayed medical assessments, and issues with dignity and respect, but fines or enforcement actions were not listed in the available reports. Most complaints without deficiencies were found unsubstantiated, and the facility has taken corrective actions such as staff training and policy updates. The inspection history shows ongoing challenges with resident safety and care processes, with some improvements noted in life safety compliance after re-inspections.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
400% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 90
Capacity: 90
Deficiencies: 2
Jun 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461426, which involved allegations related to failure to notify the physician of a resident injury and failure to ensure resident safety during transfer.
Findings
The facility failed to notify the physician when Resident B sustained a laceration injury during a transfer and failed to ensure Resident B was kept safe during the transfer, resulting in the resident being sent to the emergency room with a wound requiring staples. The facility's policies on notification and transfer safety were not fully followed.
Complaint Details
Complaint IN00461426 was substantiated with Federal/State deficiencies cited at F580 and F689 related to failure to notify the physician of injury and failure to ensure resident safety during transfer.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician when a resident sustained an injury during a transfer for 1 of 3 residents reviewed for notification of change (Resident B). | SS=D |
| Failed to ensure a resident was kept safe during a transfer for 1 of 1 resident reviewed for accidents (Resident B). | SS=D |
Report Facts
Census: 90
Total Capacity: 90
Staples required: 7
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Staff monitoring: 20
Staff monitoring: 10
Staff monitoring: 5
Compliance threshold: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Smith | RDO | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 3 | Nurse who documented notification attempts and contacted family and on-call physician | |
| Nurse Practitioner 7 | Nurse Practitioner | Interviewed regarding lack of notification to on-call provider |
| LPN 6 | Interviewed about Resident B's transfer and bed frame observation | |
| Certified Occupational Therapy Assistant 5 | Interviewed about Resident B's transfer needs and gait belt use | |
| CNA 1 | Certified Nursing Assistant | Interviewed about transfer of Resident B and use of gait belt policy |
| CNA 2 | Certified Nursing Assistant | Interviewed about transfer of Resident B |
| Director of Nursing | Director of Nursing | Interviewed about transfer procedures and documentation expectations |
| Corporate Support Nurse | Interviewed about transfer procedures and facility policies |
Inspection Report
Re-Inspection
Census: 87
Capacity: 150
Deficiencies: 0
Jun 11, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/15/2025.
Findings
The Waters of Tipton Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was fully sprinklered except for the attic above the second floor and one detached storage barn which was not sprinklered.
Inspection Report
Life Safety
Census: 88
Capacity: 150
Deficiencies: 8
Apr 15, 2025
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to conduct required emergency preparedness exercises, maintain means of egress free of obstructions, maintain fire alarm system time accuracy, ensure therapy rooms are properly separated from corridors, conduct annual fire door inspections, maintain electrical receptacle testing documentation, allow proper cool down time for emergency generator load tests, and maintain documentation for Patient Care Related Electrical Equipment testing.
Severity Breakdown
SS=F: 4
SS=E: 3
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. | SS=F |
| Failed to ensure one of four means of egress on the second floor was continuously maintained free of obstructions. | SS=E |
| Failed to maintain the fire alarm system to ensure accurate time and date information. | SS=C |
| Failed to ensure therapy rooms were separated from the corridor by a partition capable of resisting the passage of smoke. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed. | SS=E |
| Failed to ensure documentation of electrical outlet receptacle testing for all resident sleeping rooms was completed. | SS=F |
| Failed to ensure emergency generator was allowed a 5 minute cool down period after a load test. | SS=F |
| Failed to conduct required maintenance and maintain complete documentation of inspections for all Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Facility capacity: 150
Census: 88
Deficiencies cited: 8
Cool down time: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Administrator | Named in relation to findings and plan of correction |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 13
Mar 18, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00451017.
Findings
The facility was found deficient in multiple areas including failure to re-evaluate and monitor bed and chair alarms, failure to notify the Ombudsman of resident transfers and discharges, failure to hold timely care plan meetings, inadequate assistance with activities of daily living, lack of physician orders for catheters, improper respiratory care equipment management, insufficient nursing staff including lack of RN coverage for 8 consecutive hours, medication authorization delays, incomplete narcotic count documentation, lack of monitoring for psychotropic medication side effects, serving food at improper temperatures, inadequate dishwasher temperature monitoring, and infection control issues including catheter bag placement and hand hygiene.
Complaint Details
Complaint IN00451017 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 9
SS=E: 3
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure the need for a bed and chair alarm was re-evaluated and ongoing monitoring documented for 1 of 1 resident reviewed for physical restraints. | SS=D |
| Failed to ensure the Office of the State Long-Term Care Ombudsman was notified of resident transfers and discharges for 4 of 4 residents reviewed. | SS=E |
| Failed to ensure care plan meetings were held quarterly and timely upon admission for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure dependent residents were assisted to the bathroom timely and with proper footwear according to physician orders for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure residents with catheters had physician orders in place for 3 of 4 residents reviewed for catheters. | SS=D |
| Failed to label oxygen lines with date, store oxygen lines properly, and discard unused nebulizer equipment for 3 of 3 residents reviewed for respiratory care. | SS=D |
| Failed to ensure sufficient nursing staff were available to provide care to residents, affecting all 88 residents. | SS=F |
| Failed to ensure Registered Nurse coverage was provided for at least 8 consecutive hours in a 24-hour day for 1 of 14 days reviewed. | SS=D |
| Failed to ensure pharmacy received medication authorization timely and narcotic count sheets were signed by incoming and outgoing staff for 4 narcotic logs reviewed. | SS=D |
| Failed to ensure monitoring for potential side effects of psychotropic medications were in place for 1 of 5 residents reviewed. | SS=D |
| Failed to ensure food was served at palatable and appetizing temperatures for 1 of 1 room tray observed. | SS=D |
| Failed to ensure staff used adequate testing equipment and working thermometers to ensure adequate washing of dishware in the high temperature dishwasher. | SS=F |
| Failed to ensure catheter bags were not touching the floor, dental staff wore PPE properly, and hand hygiene was performed before and after tasks for residents and staff observed. | SS=E |
Report Facts
Census: 88
Deficiencies cited: 14
Staffing rating: 1
Narcotic log missing signatures: 12
Room tray temperature: 110
Room tray temperature: 85
Dishwasher wash temperature: 155
Dishwasher rinse temperature: 180
Resident wait time: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Administrator | Signed report and involved in interviews |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies and policies |
| Executive Director | Executive Director | Interviewed regarding staffing and notification processes |
| LPN 5 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene and narcotic counts |
| QMA 17 | Qualified Medication Aide | Observed and interviewed regarding resident care and staffing |
| Kitchen Manager 16 | Kitchen Manager | Interviewed regarding food temperatures and dishwasher issues |
| Corporate Support Nurse 1 | Corporate Support Nurse | Provided policies and interviewed regarding pharmacy services |
| Pharmacy Staff 10 | Pharmacy Staff | Interviewed regarding medication authorization |
| Pharmacy Staff 11 | Pharmacy Staff | Interviewed regarding medication authorization |
| Pharmacy Staff 12 | Pharmacy Staff | Interviewed regarding medication authorization |
| Physician 9 | Physician | Interviewed regarding medication orders |
| Dietary Manager | Dietary Manager | Interviewed and provided education on food service |
| Cook 21 | Cook | Interviewed regarding dishwasher temperature |
| Cook 23 | Cook | Interviewed regarding dishwasher temperature |
| Maintenance 24 | Maintenance Staff | Interviewed regarding dishwasher temperature gauge |
| Dietary Support 25 | Dietary Support Staff | Interviewed regarding dishwasher temperature |
| Dental Staff 8 | Dental Staff | Observed wearing PPE in hallway |
Inspection Report
Renewal
Deficiencies: 0
Mar 18, 2025
Visit Reason
Paper compliance review for the Recertification and State Licensure survey conducted on March 18, 2025.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 6, 2025
Visit Reason
The document is a paper review to verify compliance with a previously cited unrelated deficiency from December 31, 2024.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the unrelated deficiency.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 1
Dec 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00447794 and IN00444685 at Waters of Tipton Skilled Nursing Facility.
Findings
No deficiencies were cited related to the allegations in the complaints. However, an unrelated deficiency was cited regarding the failure to ensure unlicensed staff notified licensed staff when a resident was found to have bruising of unknown origin on both shoulders.
Complaint Details
Complaint IN00447794 and IN00444685 were investigated with no deficiencies related to the allegations cited. The unrelated deficiency involved failure to notify licensed staff of bruising found by unlicensed staff.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure unlicensed staff notified a licensed staff member when a resident was found to have discolored areas (bruising) on both shoulders for 1 of 1 resident reviewed for injury of unknown origin. | SS=D |
Report Facts
Census: 81
Total Capacity: 81
Medicare Residents: 10
Medicaid Residents: 47
Other Residents: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Administrator | Signed the report |
| Director of Nursing | Named in relation to findings and plan of correction but no full name provided | |
| QMA 3 | Interviewed regarding notification procedures for skin issues | |
| LPN 5 | Interviewed regarding skin issue assessments and documentation | |
| LPN 6 | Interviewed regarding skin issue notification and documentation |
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Jun 21, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00432760 completed on April 29, 2024.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regards to the PSR to the Investigation of Complaint IN00432760.
Complaint Details
Complaint IN00432760 - Corrected.
Report Facts
Census SNF beds: 27
Census SNF/NF beds: 65
Total census: 92
Medicare census: 27
Medicaid census: 53
Other payor census: 12
Inspection Report
Re-Inspection
Census: 87
Capacity: 150
Deficiencies: 0
May 8, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/21/24 by the Indiana Department of Health.
Findings
The Waters of Tipton Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 150
Census: 87
Inspection Report
Complaint Investigation
Census: 91
Capacity: 91
Deficiencies: 1
Apr 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00432760 and IN00433531. Complaint IN00432760 resulted in a federal/state deficiency citation, while complaint IN00433531 had no deficiencies cited.
Findings
The facility failed to ensure a resident with severe cognitive impairment had appropriate assistive devices in place to prevent a fall from her wheelchair. This resulted in the resident falling forward from her wheelchair, sustaining a subarachnoid hemorrhage and other injuries requiring hospitalization. The root cause was identified as staff transporting the resident without foot pedals on the wheelchair. The facility implemented corrective actions including audits, staff in-service training, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00432760 was substantiated with a federal/state deficiency cited at F689 related to the allegations. Complaint IN00433531 had no deficiencies related to the allegations.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident with cognitive impairment had assistive devices in place to prevent a fall from her moving wheelchair, resulting in injury. | SS=G |
Report Facts
Census: 91
Licensed capacity: 91
Date of fall: Apr 13, 2024
Date of survey: Apr 26, 2024
Date of survey completion: Apr 29, 2024
Wound measurements: 5
Wound measurements: 1.8
Wound measurements: 2.1
Wound measurements: 0.1
Pain scale: 5
Audit date: May 24, 2024
In-service training date: May 28, 2024
Plan of correction completion date: May 29, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Waymire | Administrator | Signed the report and plan of correction |
| CNA 1 | Involved in transporting Resident B when fall occurred; educated on safe transfers | |
| Director of Nursing | DON | Completed audit of cognitively impaired residents using wheelchairs and oversaw corrective actions |
| Executive Director | ED | Interviewed regarding wheelchair assessments and facility policies |
| Rehabilitation Program Manager | Interviewed regarding wheelchair provision and fitting |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 19, 2024
Visit Reason
Paper compliance review related to the Recertification and State Licensure Survey and the Investigation of Complaints IN00428961 and IN00428020 completed on March 8, 2024.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure Survey and the Investigation of Complaints.
Inspection Report
Annual Inspection
Census: 89
Capacity: 150
Deficiencies: 6
Mar 21, 2024
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) on 03/21/2024.
Findings
The facility was found not in compliance with several Life Safety Code requirements including fire alarm annunciation accessibility, sprinkler system maintenance, corridor door functionality, smoke barrier penetrations, GFCI receptacle maintenance, and smoking area maintenance. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
SS=F: 2
SS=E: 3
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure fire alarm control units in non-continuously occupied areas had annunciation readily accessible to responding personnel. | SS=F |
| Failed to maintain sprinkler systems with required internal inspections and spare sprinkler heads. | SS=F |
| Failed to ensure 2 corridor doors were provided with means suitable for keeping the door closed, latching, and resisting passage of smoke. | SS=E |
| Failed to ensure penetrations through 1 of 8 smoke barrier walls were protected to maintain smoke resistance. | SS=E |
| Failed to ensure 1 of over 20 GFCI receptacles was properly maintained for protection against electric shock. | SS=D |
| Failed to ensure 2 of 3 smoking areas were maintained by disposing cigarette butts in metal or noncombustible containers with self-closing cover devices. | SS=E |
Report Facts
Facility capacity: 150
Census: 89
Number of fire alarm control units: 2
Number of sprinkler systems: 2
Number of corridor doors: 2
Number of smoke barrier walls: 8
Number of GFCI receptacles: 1
Number of smoking areas: 3
Cigarette butts observed: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Roe | Administrator | Named in relation to exit conference and plan of correction |
| Maintenance Director | Interviewed and involved in observations and corrective actions | |
| Maintenance Supervisor | Responsible for corrective actions and monitoring |
Inspection Report
Annual Inspection
Census: 93
Capacity: 93
Deficiencies: 6
Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00428961 and IN00428020.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders and assessments for personal body alarms, failure to notify a resident's responsible party of an abuse allegation, inadequate pain management for a resident, improper medication storage including expired insulin pens and unlabeled OTC medications, insufficient dietary staff competency in dishwasher operation, and failure to submit the required Alzheimer's/Dementia Special Care Unit disclosure form.
Complaint Details
This visit included investigation of Complaints IN00428961 and IN00428020. Federal deficiencies related to the allegations were cited at F607.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to obtain physician's order, complete assessments, document care plans, and complete daily function testing for residents wearing personal body alarms. | SS=D |
| Failed to notify a resident's responsible party of an allegation of abuse in accordance with facility policy. | SS=D |
| Failed to assess a resident for pain, address concerns and distress, and notify the physician of resident pain and distress. | SS=D |
| Failed to discard expired insulin pen and indicate date opened on insulin pens; failed to label OTC medications with resident identifiers. | SS=D |
| Failed to ensure dietary employees had competency and skills in the operation of the dishwasher. | SS=F |
| Failed to submit required Alzheimer's/Dementia Special Care Unit disclosure form. | — |
Report Facts
Census: 93
Total Capacity: 93
Survey Dates: March 4, 5, 6, 7, and 8, 2024
Deficiencies cited: 6
Residents with personal body alarms: 2
Dementia unit beds: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Roe | Administrator | Signed the report and involved in notification of abuse allegation |
| Physical Therapy Assistant 7 | Physical Therapy Assistant | Interviewed regarding therapy assessments for fall interventions |
| RN 8 | Registered Nurse | Interviewed regarding assessments and policy on personal body alarms |
| QMA 9 | Qualified Medication Aide | Observed and interviewed regarding resident pain and medication cart observations |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding medication cart observations |
| Dietary Aide 6 | Dietary Aide | Interviewed regarding dishwasher operation |
| Dietary Manager | Dietary Manager | Interviewed regarding dishwasher operation and training |
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Feb 27, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00425077 and IN00425307 completed on January 9, 2024.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaints IN00425077 and IN00425307. Both complaints were corrected.
Complaint Details
This visit was a Post Survey Revisit to the Investigation of Complaints IN00425077 and IN00425307. Both complaints were corrected.
Report Facts
Census Bed Type Total: 94
Census Payor Type Medicare: 11
Census Payor Type Medicaid: 58
Census Payor Type Other: 25
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
Jan 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426659.
Findings
No deficiencies related to the allegations in Complaint IN00426659 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaint IN00426659 found no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 101
SNF/NF Beds: 84
SNF Beds: 17
Census Payor Type Medicare: 15
Census Payor Type Medicaid: 54
Census Payor Type Other: 32
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 2
Jan 9, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00424603, IN00425077, IN00425288, and IN00425307) regarding the facility's care and supervision of residents.
Findings
The facility failed to ensure that unlicensed staff notified licensed nursing staff immediately after a resident fall, resulting in delayed assessment and bilateral femur fractures for Resident 2. Additionally, the facility failed to provide adequate supervision and staff assistance during mechanical lift transfers, contributing to the resident's fall and injury. Both the CNA and QMA involved were terminated for violations of policy and scope of practice.
Complaint Details
Complaints IN00425077 and IN00425307 were substantiated with federal deficiencies cited at F684 and F689. Complaints IN00424603 and IN00425288 had no deficiencies related to the allegations.
Severity Breakdown
SS=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure unlicensed staff notified licensed staff immediately after a resident fall, resulting in delayed injury assessment and bilateral femur fractures (Resident 2). | SS=G |
| Failed to ensure adequate supervision and staff assistance during mechanical lift transfers, resulting in an unwitnessed fall and bilateral femur fractures (Resident 2). | SS=G |
Report Facts
Census: 104
Total Capacity: 104
Deficiencies cited: 2
Pain complaints: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Named in findings for failing to notify nurse of resident fall and improper use of mechanical lift; terminated for violations | |
| QMA 2 | Qualified Medication Aide | Named in findings for failing to notify nurse of resident fall and assessing resident outside scope of practice; terminated for violations |
| Victoria Roe | Administrator | Signed report and involved in corrective action planning |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding lack of notification of resident fall |
| Physician 8 | Physician | Interviewed regarding resident assessment after fall |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 18, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00419935 and IN00420312 completed on October 26, 2023.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the Investigation of Complaints IN00419935 and IN00420312.
Complaint Details
Investigation of Complaints IN00419935 and IN00420312; paper compliance completed and found in compliance.
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00420576 and IN00422146 at The Waters of Tipton Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaints investigated.
Complaint Details
Complaint IN00420576 and Complaint IN00422146 were investigated with no deficiencies found related to the allegations.
Report Facts
Census: 94
SNF beds: 22
SNF/NF beds: 72
Medicare residents: 10
Medicaid residents: 63
Other payor residents: 21
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Oct 26, 2023
Visit Reason
This visit was for the investigation of multiple complaints (IN00420312, IN00419935, IN00420123, IN00420049, IN00420051, IN00420061, IN00418007) at Waters of Tipton Skilled Nursing Facility.
Findings
The facility was found deficient in ensuring residents were treated with respect and dignity, specifically involving CNA 1 who was terminated due to customer service issues. Additionally, the facility failed to ensure timely completion of a chest X-ray for a resident, resulting in delayed diagnosis and hospitalization.
Complaint Details
Complaint IN00420312 was substantiated with a deficiency cited at F776 related to delayed radiology services. Complaint IN00419935 was substantiated with a deficiency cited at F550 related to resident rights and dignity. Other complaints (IN00420123, IN00420049, IN00420051, IN00420061, IN00418007) had no deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with respect and dignity, involving rough and disrespectful care by CNA 1. | SS=D |
| Failure to ensure a chest X-ray was completed timely for a resident, leading to delayed diagnosis of Legionella pneumonia. | SS=D |
Report Facts
Census: 109
SNF beds: 28
SNF/NF beds: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Roe | Administrator | Signed report as Administrator |
| CNA 1 | Named in deficiency related to resident dignity and customer service issues leading to termination | |
| Executive Director | Executive Director | Interviewed regarding termination of CNA 1 |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding delayed chest X-ray and resident hospitalization |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding missing chest X-ray results |
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Sep 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416085 at the Waters of Tipton Skilled Nursing Facility.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00416085 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 28
Census SNF/NF beds: 84
Total census: 112
Medicare census: 9
Medicaid census: 64
Other payor census: 39
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409507.
Findings
No deficiencies related to the allegations in Complaint IN00409507 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00409507 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 25
Census SNF/NF beds: 73
Total census: 98
Medicare census: 19
Medicaid census: 51
Other payor census: 28
Inspection Report
Re-Inspection
Census: 98
Capacity: 150
Deficiencies: 0
Mar 29, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/07/23 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this Life Safety Code Survey, The Waters of Tipton Skilled Nursing Facility was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Annual Inspection
Census: 98
Capacity: 150
Deficiencies: 15
Mar 7, 2023
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor obstructions, exit door accessibility, emergency lighting testing, hazardous area protections, cooking facility safety, sprinkler system maintenance, fire extinguisher installation, combustible decorations, fire drills, fire door inspections, electrical receptacle testing, power strip usage, and oxygen cylinder storage.
Severity Breakdown
SS=E: 7
SS=F: 5
SS=D: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Corridor means of egress were obstructed by a chair and overbed table. | SS=E |
| Exit door at the Main entrance was magnetically locked without posted access code. | SS=E |
| Battery backup emergency lights were not tested annually for 90 minutes. | SS=F |
| Storage room on 2nd floor dining area with large combustible storage was not protected as a hazardous area. | SS=E |
| Staff did not have access to shutoff switch for electric range in back Dining room. | SS=D |
| Sprinkler system internal pipe inspection documentation was not found for last 5 years. | SS=F |
| Portable fire extinguisher in maintenance shop was unsecured and sitting on the floor. | SS=D |
| Room with large combustible storage open to corridor was used as hazardous storage; nursing station pass-through window exceeded allowed size without proper protection. | SS=E |
| Two corridor doors lacked proper latching hardware and did not close properly. | SS=E |
| Fire drills were not conducted on each shift for 2 of 4 quarters. | SS=F |
| Corridor door was covered with combustible decorations exceeding 30% of door area. | SS=D |
| Annual inspection and testing of fire door assemblies was not completed within the last year. | SS=F |
| Non-hospital grade electrical receptacles in resident sleeping rooms were not tested annually. | SS=F |
| Power strip was used as a substitute for fixed wiring to power high current draw equipment. | SS=E |
| Empty oxygen cylinders were not segregated from full cylinders and not marked to avoid confusion. | SS=E |
Report Facts
Deficiency count: 15
Census: 98
Total capacity: 150
Fire drills missing: 2
Battery backup emergency lights: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Juday | Administrator | Named in relation to plan of correction and exit conference. |
| Brenda Buroker | Director, Long term Care Division, Indiana State Department of Health | Named in plan of correction correspondence. |
Inspection Report
Renewal
Deficiencies: 0
Feb 27, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on February 27, 2023.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 93
Capacity: 93
Deficiencies: 6
Feb 21, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 21 to 27, 2023.
Findings
The facility was found deficient in multiple areas including resident dignity related to urinary catheter privacy, informed consent for psychotropic medications, fall prevention interventions, pain management, food safety and sanitation, and infection control practices.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide privacy covers for urinary catheter drainage bags for 3 residents. | SS=D |
| Failed to ensure residents receiving psychotropic medications had benefits and risks reviewed with them or their representatives for 4 residents. | SS=E |
| Failed to implement fall prevention interventions for 2 residents at risk for falls. | SS=D |
| Failed to ensure pain assessments were completed to monitor effectiveness of pain medications for 1 resident. | SS=D |
| Failed to maintain ice machine and kitchen sanitation, including improper sweeping during food preparation. | SS=D |
| Failed to follow infection control procedures including hand hygiene before donning PPE, sanitizing equipment, and proper PPE use by staff. | SS=D |
Report Facts
Survey dates: 5
Residents reviewed for psychotropic medications: 5
Residents reviewed for dignity related to catheter bags: 3
Residents reviewed for falls: 3
Residents reviewed for pain management: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Juday | Administrator | Signed plan of correction and contact for further information. |
| Brenda Buroker | Director, Long Term Care Division, Indiana State Department of Health | Recipient of plan of correction submission. |
| CNA 7 | Observed failing to perform hand hygiene and improper PPE use. | |
| CNA 9 | Observed failing to perform hand hygiene. | |
| LPN 8 | Observed failing to sanitize vital sign machine and perform hand hygiene. | |
| Director of Nursing | DON | Provided interviews regarding deficiencies and corrective actions. |
| Assistant Director of Nursing | ADON | Provided interviews regarding deficiencies and corrective actions. |
| Dietary Manager | Provided interview regarding ice machine contamination and food prep sanitation. | |
| Qualified Medication Aide 3 | QMA | Interviewed regarding catheter bag dignity issue. |
| Social Service Worker 5 | SSW | Interviewed regarding psychotropic medication consent documentation. |
| Social Service Worker 6 | SSW | Interviewed regarding psychotropic medication consent documentation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 16, 2023
Visit Reason
Paper compliance review related to an unrelated deficiency cited during a complaint investigation completed on January 9, 2023.
Findings
The Waters of Tipton Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the unrelated deficiency.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00392907 at The Waters of Tipton Skilled Nursing Facility.
Findings
The facility failed to ensure the safety of a resident with dementia and Parkinson's disease who was found outside the facility after being placed on a locked unit. The resident was able to exit the secured Memory Care unit through a window that was partially open and missing a screen. The resident had a history of elopement risk and exhibited behaviors including delusions and paranoia. The facility implemented corrective actions including increased monitoring, securing windows, changing door codes, and staff education.
Complaint Details
Complaint IN00392907 was substantiated. No deficiencies related to the allegations were cited, but an unrelated deficiency was cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure the safety of a resident with dementia and Parkinson's disease who was found outside the facility after being placed on a locked unit. | SS=D |
Report Facts
Census: 88
Skilled Nursing Facility beds: 22
SNF/NF beds: 66
Medicare residents: 13
Medicaid residents: 46
Other residents: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Juday | Administrator | Signed plan of correction and correspondence |
| Brenda Buroker | Director, Long term Care Division, Indiana State Department of Health | Recipient of plan of correction |
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