Tipton Oak Manor

In the surveyor’s words

From the most serious findings on record at Tipton Oak Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Aug 1, 2024

  Based 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… […]

• No harm, potential for more than minimal, widespreadF880Aug 1, 2024

  Based 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… […]

• No harm, potential for more than minimal, widespreadF812Mar 9, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF610Mar 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF727Mar 12, 2026

  Based 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. […]