Inspection Reports for
The Waters of Tipton Skilled Nursing Facility

This citation relates to Intake 2659059. The complaint was substantiated based on interviews and observations confirming inappropriate treatment of residents B and C.

The facility failed to ensure residents were treated with respect and dignity. Resident B was sprayed with wound cleanser and marked on the forehead by a staff member, and Resident C had his beard, mustache, and eyebrows shaved without proper consent.

The facility failed to develop and implement a person-centered care plan with individualized interventions for a resident with dementia prior to initiating medication to control behaviors. The facility also failed to ensure proper assessment and documentation of the use of medication for behavioral control and did not maintain complete and accurate clinical records of the resident's inappropriate sexual behaviors.

This citation relates to Complaint IN00461426. The complaint involved failure to notify the physician and family of Resident B's injury and unsafe transfer practices.

The facility failed to notify the physician timely when Resident B sustained a laceration requiring staples during a transfer. The facility also failed to ensure safe transfer practices, as Resident B was transferred without a gait belt despite policy and required assistance.

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.

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.

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.

Complaint IN00451017 was investigated with no deficiencies related to the allegations cited.

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.

The facility had multiple deficiencies including failure to document re-evaluation and monitoring of physical restraints, failure to notify the Ombudsman of resident transfers and discharges, incomplete care plan meetings, inadequate assistance with activities of daily living, missing physician orders for catheters and oxygen use, insufficient nursing staff coverage, medication management issues including delayed medication authorization and incomplete narcotic log signatures, failure to monitor side effects of psychotropic medications, serving food at unsafe temperatures, inadequate dishwasher temperature monitoring, and lapses in infection control practices.

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.

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.

The complaint investigation found that unlicensed staff did not notify licensed staff about bruising on Resident 2, and the facility lacked an initial licensed nurse assessment. The issue was substantiated with findings of minimal harm.

The facility failed to provide an initial licensed nurse assessment when bruising was found on Resident 2's shoulders. Documentation and communication protocols regarding skin assessments by unlicensed staff were not properly followed.

This citation relates to Complaint IN00432760. The complaint involved a fall on 4/13/24 where Resident B fell from her wheelchair due to missing foot pedals during transport, resulting in injury and hospitalization.

The facility failed to ensure a resident with severe cognitive impairment had proper assistive devices, specifically foot pedals on her wheelchair, during transport. This failure resulted in the resident falling from her wheelchair, sustaining a subarachnoid hemorrhage and other injuries requiring hospitalization.

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.

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.

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.

This visit included investigation of Complaints IN00428961 and IN00428020. Federal deficiencies related to the allegations were cited at F607.

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.

The facility was found deficient in multiple areas including failure to obtain physician orders and complete assessments for residents using personal body alarms, failure to notify a resident's responsible party of an abuse allegation, inadequate pain management for a resident, improper labeling and storage of medications, and insufficient competency of dietary staff in dishwasher operation.

The deficiency relates to complaints IN00428020 and IN00428961. The allegation involved verbal abuse by a CNA toward Resident B, and the facility failed to notify the resident's family as required.

The facility failed to notify a resident's responsible party of an allegation of verbal abuse by a staff member. The investigation confirmed that a CNA spoke to a resident in an upset tone and pointed a finger at the resident, but the family was not informed as required by facility policy.

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.

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.

This Federal tag relates to Complaints IN00425077 and IN00425307. The complaint investigation focused on the fall incident involving Resident 2 on 12/22/23, the failure to notify nursing staff, and inadequate supervision during transfers.

The facility failed to ensure that an unlicensed staff member notified a licensed nurse immediately after Resident 2 experienced a fall, resulting in delayed assessment and treatment of bilateral femur fractures. Additionally, the facility failed to provide adequate supervision and staff assistance during transfers, contrary to the resident's care plan requiring two-person mechanical lift assistance.

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.

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.

The complaint investigation was triggered by allegations of disrespectful treatment by CNA 1 toward residents, including rough handling and poor customer service. The investigation also included a review of diagnostic service delays related to a resident's chest X-ray.

The facility failed to ensure residents were treated with respect and dignity, as evidenced by complaints against CNA 1 for rough and disrespectful care. Additionally, the facility failed to ensure a chest X-ray was completed timely for a resident with pneumonia symptoms, resulting in delayed diagnosis and hospitalization.

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.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering urinary catheter bags, inadequate informed consent for psychotropic medications, failure to implement fall prevention interventions, incomplete pain assessments, improper food safety practices, and lapses in infection control procedures.

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.

Complaint IN00392907 was substantiated. No deficiencies related to the allegations were cited, but an unrelated deficiency was cited.

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.