Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tipton Oak Manor during CMS and state inspections, most recent first.
Facility staff failed to complete a thorough investigation after two residents had missing Fentanyl patches. Both residents were severely cognitively impaired and received scheduled opioid pain meds. Staff documented that the patches were not found after searching the residents, rooms, clothing, and linens, and the DON was notified, but there was no further documentation or investigation completed.
Facility staff failed to provide RN coverage for at least 8 consecutive hours per day, 7 days a week. Policies and the Facility Assessment did not direct staff on the RN coverage requirement, and staff schedules showed multiple days across several months when no RN was scheduled for the required 8-hour period. During interviews, an LPN, the DON, and the Administrator described using agency staff, the DON, and the MDS Coordinator to fill gaps, while acknowledging the facility knew the 8-hour RN coverage requirement.
Incomplete TB screening documentation was found for multiple staff and residents. Five of eight employee files lacked required two-step PPD documentation or read/admin dates, and five of ten sampled residents had TB tests documented without recorded results. The DON, charge nurses, and Administrator were responsible for the process, but were unaware of the missing documentation.
An LPN provided wound care to a resident with recurrent stage II buttock wounds without performing hand hygiene before entering or after leaving the room, and used the same gloves throughout the task. The resident had severe cognitive impairment, diabetes, cancer, heart failure, moisture associated skin damage, bowel incontinence, and a history of repeated buttock pressure injuries, while the care plan did not address the current wound or updated interventions.
Facility staff failed to properly label and date insulin pens, leading to multiple opened and undated pens in medication carts. Interviews with CMTs, an LPN, the DON, and the administrator revealed inconsistent practices in labeling, despite facility policies and signage requiring dating upon opening. The facility relied on monthly pharmacy checks, which were insufficient for ensuring immediate compliance.
Facility staff failed to follow infection control procedures, leading to deficiencies in resident care. The DON did not change gloves or wash hands during wound care and medication administration for residents with cognitive impairments and medical devices. PPE was not available as required by the EBP policy, and staff were unaware of which residents needed precautions. These actions violated the facility's infection control policies.
Facility staff failed to update care plans for three residents regarding smoking supervision, despite policy requirements. Observations showed residents smoking unsupervised with cigarettes and lighters on them, contrary to care plans. Interviews revealed a lack of awareness and communication about care plan requirements among staff.
Facility staff failed to check the placement of a G-Tube before administering feeding and medications to a resident, contrary to facility policy. The resident, dependent on staff for nutrition due to dysphagia, had specific physician orders for 100 ml water flushes before and after feedings. Observations showed that the DON and LPNs did not adhere to these orders, administering less water than prescribed. Interviews revealed a lack of adherence to protocols, with staff misreading or forgetting the physician's orders.
The facility failed to post required nurse staffing information daily, as observed over three days. An LPN was aware of the requirement but had not seen the postings, while the DON was unaware of the need for daily updates. The administrator acknowledged responsibility but had not designated anyone to perform this duty, resulting in non-compliance.
Facility staff failed to ensure privacy for two residents during wound care and medication administration, leaving doors and curtains open. Additionally, signs with personal information were improperly displayed in a public area, visible to other residents and visitors. Staff interviews confirmed the breach of privacy.
Missing Fentanyl Patches Not Investigated
Penalty
Summary
Facility staff failed to initiate and complete a thorough investigation after two residents had missing Fentanyl patches. The facility policy required allegations of misappropriation of resident property to be reported immediately, and the event investigation policy required documentation of the medication event, physician notification, actions taken to prevent recurrence, and completion of the investigation with required signatures and follow-up documentation. The report states that staff did not complete further documentation or investigation for either incident. One resident was severely cognitively impaired and had orders for a Fentanyl patch 12 mcg every 72 hours for pain. The resident's order sheet and MAR did not specify where the patch should be placed on the body. Staff documented that the patch was missing during night shift rounds, and aides reported the resident had been pulling at it. The nurse and aides searched the resident's clothing, linens, and body but could not find the patch. The nurse reported the missing patch to the DON. A second resident was also severely cognitively impaired and received scheduled pain medication and opioid medications, including a Fentanyl patch 12 mcg every 72 hours. The order and MAR did not specify where to place the patch on the resident's body. A CMT documented that the patch was not on the resident, searched the room, clothing, and laundry, and reported the missing patch to the charge nurse. The nurses' note documented the patch was missing from the resident's back, a new patch was applied and covered with a clear dressing, and the DON was notified. During interviews, the DON stated there was no further documentation beyond the patches being missing and said he/she was not aware of reporting procedures or proper investigation requirements. The Administrator stated he/she was not aware of the two missing patches or the lack of follow-up documentation or investigation.
RN Coverage Not Provided as Required
Penalty
Summary
Facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, for a census of 53.1 residents. Review of the facility’s policies showed no policy directing staff on RN coverage requirements, and the Facility Assessment Tool dated 2/27/26 did not direct staff on RN coverage seven days a week for eight consecutive hours. Review of staff schedules showed multiple dates in December 2025, January 2026, February 2026, and March 2026 when the facility did not have an RN for eight consecutive hours. During interviews on 03/12/26, an LPN said that when there was no RN scheduled for the weekend, the shift was posted for agency to pick up and that the DON would pick up shifts as needed. The DON said the facility used agency staff when weekend RN coverage was missing and that the MDS Coordinator would also pick up shifts if agency did not. The Administrator said the facility had an RN covering night shift from 10:00 P.M. to 6:00 A.M. and that the DON and MDS Coordinator covered as needed, and stated they were not aware the facility was not meeting the RN coverage requirement.
Incomplete TB Screening Documentation for Staff and Residents
Penalty
Summary
Facility staff failed to use appropriate infection control procedures when TB screening documentation was incomplete for both employees and residents. Review of the facility policy titled Tuberculosis Control showed that the first step PPD was to be administered by nursing, documented on the Employee Immunization record, and read prior to or no later than the start date, with a second test required one to three weeks later if the initial result was 0-9 mm. In review of eight employee files, five were missing required TB testing documentation: Dietary Aide C and CMT D had two-step PPDs documented without read dates, LPN F did not have a two-step TB test, Laundry Aide G had read dates documented without administration dates, and CNA H had a first-step PPD documented without a read date. Staff interviews showed the DON, charge nurses, and Administrator were responsible for TB testing and documentation, but the DON and Administrator were not aware of the missing dates and incomplete records. Resident records also showed incomplete TB screening documentation for five of ten sampled residents. Resident #9 had a second-step TB test documented without results; Resident #31 had a first-step TB test documented without results; and Residents #33, #41, and #49 each had first- and second-step TB tests documented without recorded results. The DON stated nurses were responsible for initiating the first-step TB test on admission and ensuring residents received the two-step TB tests, and said the read dates were not documented because the forms used did not have a place to record them. The Administrator stated he/she was not aware the TB tests were not completed and said oversight of the process was the DON's responsibility.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
Facility staff failed to ensure appropriate pressure ulcer care and prevention for one resident with a history of recurrent skin breakdown and current stage II wounds. Resident #37 had severe cognitive impairment, diabetes mellitus, cancer, heart failure, moisture associated skin damage, and was at risk for pressure ulcers/injuries. The resident’s skin assessments documented multiple pressure injuries and healed/reopened areas over several months, including stage II wounds to the buttocks and new areas appearing on both the left and right buttocks. The resident’s care plan, dated 01/22/26, did not address the resident’s history of pressure ulcers, the current stage II wound, or updated interventions since 4/24/24. During wound care observation, an LPN entered the resident’s room without performing hand hygiene, put on gown and gloves, and applied Calmoseptine ointment to the resident’s bottom using the same gloves after assisting the resident to stand and pull down pants. The LPN then removed gloves and left the room without performing hand hygiene. The resident also had bowel incontinence, a catheter, and refused to off load and lie in bed during the day, and the LPN stated the resident’s skin was difficult and that care plans should address wound interventions and refusals of care. The DON and administrator stated staff should perform hand hygiene before and after care and change gloves between dirty and clean tasks, but the observed care did not follow those practices.
Failure to Properly Label and Date Insulin Pens
Penalty
Summary
The facility staff failed to store medications in a safe and effective manner, specifically with insulin pens used to treat high blood sugar. Observations revealed that multiple insulin pens, including Lantus, Novolog, Tresiba, Fiasp, and Humalog, were opened and undated in various medication carts and rooms. This lack of proper labeling and dating of insulin pens was contrary to the facility's policy, which requires all medications to be labeled with the resident's full name, room number, and expiration date, among other details. Interviews with Certified Medication Technicians (CMTs), a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the facility administrator highlighted a lack of consistent practice in labeling and dating insulin pens. CMTs and the LPN acknowledged the importance of dating insulin pens upon opening to ensure their effectiveness, as insulin is only viable for 28 days after opening. However, there was a discrepancy in practice, as some staff members did not consistently label the pens, leading to uncertainty about the insulin's effectiveness. The facility's policy and signage in medication rooms clearly stated the requirement to date insulin upon opening and discard it after 28 days. Despite this, the DON and administrator admitted to gaps in monitoring and ensuring compliance with these procedures. The facility relied on a monthly pharmacy check to identify expired medications, but this was insufficient to address the immediate need for proper labeling and dating of insulin pens by the staff responsible for administering them.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to adhere to proper infection control procedures, leading to deficiencies in the care of residents. During wound care for a resident with cognitive impairment and open lesions, the Director of Nursing (DON) did not change gloves between treating different wounds on the resident's face and failed to wash hands before leaving the room. This action was contrary to the facility's infection control policies, which require changing gloves and washing hands between tasks to prevent the spread of infection. In another instance, the DON administered medication to a resident with a gastrostomy tube without washing hands before the procedure and failed to change gloves between administering tube feeding and sublingual medication. Additionally, the facility did not have personal protective equipment (PPE) readily available outside the resident's room, as required by the Enhanced Barrier Precautions (EBP) policy. This policy mandates the use of gloves and gowns for residents with indwelling medical devices or wounds to prevent the transmission of multidrug-resistant organisms. Interviews with staff revealed a lack of awareness and understanding of the EBP policy and which residents required such precautions. The Certified Medication Technician and a Certified Nursing Assistant were unaware of the indicators for residents needing EBP, and the DON acknowledged the incorrect signage and lack of PPE availability. The facility's failure to implement and educate staff on EBP and proper infection control measures contributed to the deficiencies observed.
Failure to Update Smoking Care Plans
Penalty
Summary
The facility staff failed to update care plans regarding smoking for three residents out of six sampled, despite the facility's policy requiring care plans to be revised as changes occur in a resident's condition. The care plans for these residents indicated that they should have supervised smoking in designated areas, with cigarettes and lighters kept at the nursing station. However, observations showed that these residents were smoking outside without staff supervision and had cigarettes and lighters on their person, contrary to their care plans. The Care Plan Coordinator and the Director of Nursing were unaware that the care plans required supervision and storage of smoking materials at the nursing station. Interviews with the Care Plan Coordinator, Director of Nursing, and the administrator revealed a lack of awareness and communication regarding the care plan requirements for smoking supervision. The Care Plan Coordinator acknowledged the responsibility to update care plans but admitted that the recent policy update had not been reflected in the care plans. The Director of Nursing and the administrator both stated that residents do not need supervision while smoking and can keep cigarettes and lighters on them, which contradicts the care plans. This discrepancy indicates a failure to ensure that care plans are current and accurately reflect the residents' needs and facility policies.
Failure to Follow G-Tube Protocols and Physician Orders
Penalty
Summary
Facility staff failed to maintain professional standards of care by not checking the placement of a Gastrostomy Tube (G-Tube) before administering feeding and medications to a resident. The facility's policy requires staff to verify tube placement by auscultation or aspiration before administering any substances through the G-tube. However, observations showed that the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) did not adhere to this protocol, as they administered medications and feedings without verifying the tube's placement. The resident involved was assessed to be dependent on staff for all nutrition and fluids, receiving all nutrition and medications through a G-tube due to dysphagia. The resident's care plan and physician's orders specified that the G-tube should be flushed with 100 ml of water before and after each bolus feeding. Despite these clear instructions, staff consistently failed to administer the correct amount of water flushes as ordered. Observations revealed that the DON and LPNs administered significantly less water than prescribed, with one instance of only 50 ml being used instead of the required 100 ml. Interviews with the staff, including the DON and LPNs, highlighted a lack of adherence to the physician's orders and facility policies. The DON admitted to not checking tube placement unless resistance was met and defaulting to a 50 ml flush due to not remembering the exact order. LPNs also misread or misunderstood the physician's orders, leading to incorrect administration of water flushes. The facility administrator emphasized the expectation for staff to follow physician's orders, which was not consistently met in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to complete or post the required nurse staffing information, which includes 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. This information was not posted in an area readily accessible to residents and visitors, despite the facility having a census of 70. The facility did not provide a policy for the daily nurse staff posting. Observations on three consecutive days showed that the nurse staffing information was not posted. During interviews, an LPN acknowledged awareness of the requirement but had not seen the postings, attributing the task to the night shift staff. The DON was unaware of the need for daily updates and postings, and the administrator admitted it was his responsibility but had not designated anyone to perform this duty, leading to the lapse in compliance.
Privacy Breach During Resident Care and Information Display
Penalty
Summary
Facility staff failed to maintain the privacy and confidentiality of two residents during care activities. Resident #14, who was assessed with severe cognitive impairment and required non-surgical dressings, was observed receiving wound care from the Director of Nursing (DON) with the privacy curtain and door open, allowing other residents to see into the room. Similarly, Resident #4, also with severe cognitive impairment and a feeding tube, was administered medication by the DON with the privacy curtain and door open, exposing the resident to passersby in the hallway. Additionally, the facility displayed signs in the day room that included the names, room numbers, and medical reasons for Enhanced Barrier Precautions (EBP) for Residents #14 and #4. These signs were visible to other residents and visitors over several days. Interviews with facility staff, including a Certified Nurse Aid (CNA) and a Certified Medication Technician (CMT), confirmed that the signs should not have been placed in a public area, and the DON acknowledged that such information should be kept at the nurses' station.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tipton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| California Care Center | 12.4 mi | ★★★★★ | 5 | 0 |
| Katy Manor | 16.2 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Care Center | 16.3 mi | ★★★★★ | 0 | 0 |
| Golden Age Living Center | 18.1 mi | ★★★★★ | 1 | 0 |
| Four Seasons Living Center | 19.5 mi | ★★★★★ | 33 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.