Waters of Tipton Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Tipton Skilled Nursing Facility, The, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 30, 2026

  Based on interview and record review, the facility failed to ensure a resident was transferred according to her plan of care, was free from an injury of unknown origin, and the investigation into the injury contained complete documentation for 1 of 2 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B receiving a mildly impacted and displaced fracture of the proximal right humerus (the ball-shaped upper portion of the arm bone which forms the shoulder joint).Findings include:During a telephone interview, on 6/29/26 at 9:48 a.m., an anonymous interviewee indicated Resident B was injured in the shower. The facility indicated she fell out of bed. […]

• Actual harm, isolatedF689Mar 26, 2026

  Based on interview and record review, the facility failed to ensure a resident remained safe from accident hazards during incontinence care provided by a staff member for 1 of 8 residents reviewed for accidents. This deficient practice resulted in Resident 63 hitting her head and receiving a head laceration which required six (6) staples.Findings include:The clinical record for Resident 63 was reviewed on 3/23/26 at 8:52 a.m. The diagnoses included, but were not limited to, muscle weakness, Alzheimer's disease, dementia, and muscle wasting and atrophy.A care plan, dated 11/18/25, indicated the resident required assistance with activities of daily living. […]

• Actual harm, isolatedF692Mar 26, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident's nutritional status was assessed, risk factors were identified and addressed, interventions were implemented, and the physician was notified of the need to assess a significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 7) This deficient practice resulted in Resident 7 experiencing an approximate 22% weight loss in approximately 4 months. Findings include:During an observation, on 3/19/26 at 12:26 p.m., Resident 7 was not eating her lunch. The CNA charting indicated the resident refused her lunch. […]

• Actual harm, isolatedF689Apr 29, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident who was severely cognitively impaired and had memory problems, had assistive devices in place to prevent a fall from her moving wheelchair for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling forward from her wheelchair and sustaining a subarachnoid hemorrhage with facial, neck, and shoulder bruising which required hospitalization . Finding includes: A document, titled Indiana State Department of Health Survey Report System, indicated Resident B went to the emergency room (ER), on 4/13/24, upon family request after a fall, while being transferred back to her room in her wheelchair. She was sent back to the facility without any injuries. […]

• Actual harm, isolatedF684Jan 9, 2024

  Based on interview and record review, the facility failed to ensure an unlicensed staff notified a licensed staff member that a dependent resident experienced a fall before transferring the resident from the floor to a wheelchair. This deficient practice resulted in the resident not being immediately assessed for injury by a licensed nurse and the resident experienced bilateral femur fractures. (Resident 2) Finding includes: A document, titled Indiana State Department of Health Survey Report System, dated 12/30/23 at 5:01 a.m., indicated Resident 2 had a witnessed fall on 12/22/23. At the time of the fall, the resident's skin and pain was assessed with no concerns. The physician and family were notified of the fall. […]