Inspection Reports for
Brent B Tinnin Manor
220 EUEL POLK DR, ELLINGTON, MO, 63638-7967
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
67% occupied
Based on a March 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 40
Deficiencies: 14
Date: Mar 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident fund security, notification of Medicare coverage, employee background checks, transfer and discharge notifications, significant change assessments, hospice care, respiratory care, nurse aide training, quality assurance programs, infection control, antibiotic stewardship, and vaccination protocols.
Findings
The facility had multiple deficiencies including failure to maintain adequate surety bond for residents' funds, failure to properly document Medicare non-coverage notices, incomplete employee background checks prior to hire, failure to provide timely transfer/discharge notifications and bed hold policy information, incomplete significant change assessments, inadequate hospice care and wound management, lack of physician orders for medication monitoring and respiratory devices, nurse aides not certified within required timeframes, absence of an implemented QAPI program, poor infection control practices, incomplete antibiotic stewardship documentation, and failure to properly document vaccination education and consent.
Deficiencies (14)
Failed to maintain surety bond at one and one-half times the average monthly balance of residents' personal funds.
Failed to properly document notification and obtain signatures for Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notice forms for three residents.
Failed to complete criminal background checks and Employee Disqualification List checks prior to hire for four employees.
Failed to provide written notice of transfer or discharge to residents or responsible parties for five residents.
Failed to notify residents or representatives in writing of the facility's bed hold policy at time of hospital transfer for six residents.
Failed to complete a significant change Minimum Data Set assessment within 14 days of admission to hospice services for one resident.
Failed to ensure hospice coordinated plan of care addressed wound care, catheter care, and repositioning; failed to follow physician orders for wound care and valproic acid level monitoring.
Failed to obtain physician order for CPAP use and failed to follow continuous oxygen order for one resident.
Failed to ensure four nurse aides completed nurse aide training program within four months of hire.
Failed to implement a Quality Assurance and Performance Improvement Plan and failed to maintain quarterly QAA/QAPI committee meetings with required members.
Failed to maintain proper infection control practices during catheter care, wound care, and incontinent care; failed to ensure enhanced barrier precautions and dedicated disposable supplies; failed to properly screen residents for tuberculosis.
Failed to maintain an antibiotic stewardship program and failed to identify appropriate indication for antibiotic use for one resident.
Failed to document education, consent, or refusal for influenza and pneumococcal vaccinations for multiple residents; administered pneumococcal vaccine to a resident who refused it.
Failed to ensure COVID-19 vaccination was offered, administered, or refused with proper education and documentation for three residents.
Report Facts
Facility census: 40
Surety bond amount: 51000
Average monthly balance: 38481.13
Number of residents with missing Medicare Non-Coverage documentation: 3
Number of employees without CBC and EDL prior to hire: 4
Number of residents without transfer/discharge notification: 5
Number of residents without bed hold policy notification: 6
Number of nurse aides not certified within 4 months: 4
Number of residents on antibiotics: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in infection control and wound care deficiencies |
| CNA G | Certified Nursing Assistant | Named in infection control deficiencies |
| CNA H | Certified Nursing Assistant | Named in infection control deficiencies |
| Administrator | Provided multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| Human Resources staff | Human Resources Staff | Interviewed about CBC and EDL checks |
| Nurse Practitioner | Nurse Practitioner | Interviewed about valproic acid lab monitoring |
| Social Service Designee | Social Service Designee | Interviewed about Medicare Non-Coverage and SNF ABN forms |
| NA B | Nurse Aide | Named in nurse aide training deficiency |
| NA D | Nurse Aide | Named in nurse aide training deficiency |
| NA F | Nurse Aide | Named in nurse aide training deficiency |
| NA G | Nurse Aide | Named in nurse aide training deficiency |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Feb 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a resident's property by the former Administrator who used the resident's bank debit card for personal use.
Complaint Details
Complaint # MO0248737. The complaint involved alleged misappropriation of Resident #1's funds by the former Administrator. The complaint was substantiated with ongoing police investigation and intent to prosecute the former Administrator.
Findings
The facility failed to protect a resident from misappropriation of property when the former Administrator used the resident's debit card to withdraw over $12,000 for personal use. The resident denied authorizing the Administrator to use the card, and the police are investigating with prosecution intended.
Deficiencies (1)
Failure to protect a resident from misappropriation of property by the former Administrator who used the resident's debit card for personal use exceeding $12,000.
Report Facts
Census: 44
Amount misappropriated: 12312.4
Dates of permission to withdraw funds: Multiple dates with specific withdrawal amounts documented in facility records
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent B Tinnin | Former Administrator (FADM) | Named in findings for misappropriation of resident funds and terminated on 01/15/2025 |
| Corporate Nurse | Corporate Nurse (CN) | Confirmed allegations during interview on 02/13/2025 |
| Acting Administrator | Acting Administrator (ADM) | Confirmed allegations during interview on 02/13/2025 |
| Prosecuting Attorney | Prosecuting Attorney (PA) | Interviewed on 02/26/2025, stated intent to prosecute the former Administrator |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Nov 18, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding a resident-to-resident abuse allegation involving two residents at the facility.
Complaint Details
The complaint investigation was triggered by an incident on 11/15/24 where Resident #2 physically hit Resident #1 multiple times, causing Resident #1 to fall from a wheelchair. Licensed Practical Nurse (LPN) A was initially informed only of a verbal altercation and did not report the physical abuse promptly. Interviews with staff and residents confirmed the physical altercation. The Director of Nurses and Administrator were notified after the fact, and the facility failed to follow proper abuse investigation protocols.
Findings
The facility failed to thoroughly investigate the resident-to-resident abuse allegation when Licensed Practical Nurse (LPN) A did not report the physical abuse allegations to the Administrator promptly. The investigation revealed that Resident #2 hit Resident #1, causing Resident #1 to fall from a wheelchair, but the facility did not document or fully investigate the abuse as required by policy.
Deficiencies (1)
Failure to thoroughly investigate a resident-to-resident abuse allegation and failure of Licensed Practical Nurse (LPN) A to report allegations of Resident #2 hitting Resident #1 to the Administrator for investigation.
Report Facts
Facility census: 52
Date of incident: Nov 15, 2024
Date of facility reported incident: Nov 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Failed to report allegations of physical abuse to the Administrator and did not investigate the abuse allegation properly. |
| CNA C | Certified Nurse Aide | Witnessed the incident and assisted Resident #1 after the fall; informed LPN A about the argument. |
| NA D | Nurse Aide | Assisted Resident #1 from the floor and informed LPN A of the physical altercation. |
| RN B | Registered Nurse | Acted as designated representative of the Administrator; investigated the incident after LPN A's report. |
| ADM | Administrator | Was on vacation during the incident; later contacted RN B to investigate the situation. |
| SO | Security Officer | Witnessed the incident and questioned Resident #2 about the physical altercation. |
Inspection Report
Routine
Census: 51
Deficiencies: 8
Date: Mar 13, 2024
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations regarding resident care, medication administration, care planning, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, failure to implement baseline care plans, failure to follow physician orders, improper Foley catheter care, failure to implement gradual dose reductions for psychotropic medications, inadequate documentation and education regarding influenza, pneumococcal, and COVID-19 vaccinations, and unsafe environment due to items placed on overbed light fixtures.
Deficiencies (8)
Failed to accurately code the Minimum Data Set (MDS) for three residents.
Failed to implement an accurate baseline care plan within 48 hours of admission for one resident.
Failed to follow physician's orders for wound care and medication administration for three residents.
Failed to ensure proper placement and care of Foley catheter tubing and drainage bags for two residents.
Failed to implement recommended gradual dose reductions (GDR) for one resident on psychotropic medication.
Failed to document accurate immunization status and provide education for influenza and pneumococcal vaccines for four residents.
Failed to document COVID-19 vaccination education and declinations for four residents.
Failed to maintain a safe environment by allowing miscellaneous items on top of overbed light fixtures.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 4
Facility census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brent B Tinnin | Administrator | Interviewed regarding expectations for MDS accuracy, baseline care plans, physician orders, vaccination education, and environmental safety. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for MDS accuracy, baseline care plans, physician orders, vaccination education, and environmental safety. |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding medication administration related to apixaban. |
| Certified Nursing Assistant A | Certified Nursing Assistant | Interviewed regarding Foley catheter care. |
| Maintenance | Interviewed regarding items on overbed light fixtures. | |
| Dentist | Interviewed regarding orders to hold apixaban prior to dental extractions. | |
| Corporate Nurse | Interviewed regarding medication administration related to apixaban. |
Inspection Report
Routine
Census: 32
Deficiencies: 7
Date: Aug 17, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements and to evaluate the quality of care and services provided at the nursing facility.
Findings
The facility was found deficient in multiple areas including inaccurate coding of resident assessments, failure to follow physician orders for medication discontinuation, incomplete hospice care coordination, unsecured chemicals in shower rooms, improper resident handling without gait belts, failure to enforce infection control policies including mask-wearing, lack of annual review of infection prevention and antibiotic stewardship programs, and inadequate pneumococcal vaccination education and documentation.
Deficiencies (7)
Failed to accurately code the Minimum Data Set (MDS) for one resident, incorrectly coding pressure ulcers and physical restraints.
Failed to follow a physician's order to discontinue medication, resulting in 77 doses given after discontinuation order.
Failed to complete and sign coordinated plan of care and lacked legal selection documentation for hospice services for one resident.
Failed to secure chemicals behind locked doors in shower rooms and failed to use gait belt when repositioning a resident.
Failed to ensure staff wore face masks and maintain social distancing per infection control policies; IPCP not reviewed or updated annually.
Failed to provide documentation of annual review of Antibiotic Stewardship Program and policies.
Failed to provide pneumococcal vaccine information and education to residents or representatives and failed to ensure second dose was offered and given.
Report Facts
Residents affected: 32
Doses of medication given after discontinuation order: 77
Residents receiving antibiotics: 2
Residents sampled: 12
Residents affected by pneumococcal vaccine deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON/MDS Coordinator | Interviewed regarding inaccurate MDS coding and hospice care coordination |
| Director of Nursing | DON | Interviewed regarding medication discontinuation, hospice care, infection control, and vaccination education |
| Certified Medical Technician C | CMT | Observed repositioning resident without gait belt |
| Housekeeper D | Housekeeper | Observed not wearing face mask during duties |
| Administrator in Training | Administrator in Training | Interviewed regarding IPCP and Antibiotic Stewardship Program reviews |
| Certified Nurse Assistant A | CNA | Interviewed regarding shower room cabinet locking |
| Registered Nurse B | RN | Interviewed regarding shower room cabinet locking |
Viewing
Loading inspection reports...
