Inspection Reports for
Brent B Tinnin Manor
220 EUEL POLK DR, ELLINGTON, MO, 63638-7967
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
215% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
67% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 40
Deficiencies: 7
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as a Life Safety Code (LSC) survey to assess compliance with fire safety regulations and related codes at Brent B Tinnin Manor.
Findings
The facility failed to meet several Life Safety Code requirements including self-closing doors in hazardous areas, discharge from exits being obstructed and locked, lack of monthly inspections on fire suppression systems, and failure to maintain smoke barrier doors. These deficiencies potentially affected all residents and staff.
Deficiencies (7)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices and those with self-closers had no impediments to closing and latching. Observations showed multiple doors had closures removed or not functioning properly.
K271 Discharge from Exits: The facility failed to maintain exit egress pathways free of obstructions. Exit gates were locked with masterlocks and chains on the exterior, preventing access from inside. Administrator ordered removal of locks during the survey.
K355 Portable Fire Extinguishers: The facility failed to maintain monthly inspections on fire suppression systems. The ANSUL system on the kitchen hood had not been inspected monthly since July 2024.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain smoke doors in operational condition. The smoke door on Sassafrass hall did not close with the fire alarm test and was repaired after observation.
A2037 Exit Requirements: The facility did not meet regulations requiring two unobstructed exits remote from each other with proper fire-rated separation and direct exit to grade level. See K271 for details.
A2054 Smoke Section Walls/Doors: Smoke sections were not properly separated by one-hour fire-rated walls and doors that are self-closing and automatically close upon fire alarm activation. See K374 for details.
A2055 Door Devices: Existing licensed facilities lacked attached self-closing devices on all doors providing separation between floors. Doors held open lacked electromagnetic hold-open devices interconnected with fire or alarm systems. See K223 for details.
Report Facts
Facility census: 40
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
Plan of Correction
Census: 44
Deficiencies: 1
Date: Feb 24, 2025
Visit Reason
The visit was conducted to investigate and document a deficiency related to misappropriation and exploitation of resident property at Brent B Tinnin Manor.
Complaint Details
Complaint # MO0248737 was investigated. The allegations of misappropriation were substantiated based on interviews and document reviews. The Prosecuting Attorney intends to prosecute the former Administrator.
Findings
The facility failed to ensure one of three sampled residents was free from misappropriation of property, with a total misappropriated amount exceeding $12,000. The former Administrator used the resident's bank debit card for personal use without permission, and the facility took corrective actions including terminating the Administrator and notifying police.
Deficiencies (1)
F602: The resident was not free from misappropriation of property as the former Administrator used the resident's bank debit card for personal use without consent. The total misappropriated amount exceeded $12,000.
Report Facts
Total misappropriated amount: 12312.4
ATM withdrawals: 803
Online purchases: 269.8
Online purchase: 232.6
Online purchase: 377
ATM withdrawal: 503
Online purchase: 799
Purchase: 1364
Withdrawals with permission: 1509
Withdrawals with permission: 387
Withdrawals with permission: 1566
Withdrawals with permission: 2397
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: 2
Date: Nov 18, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving two residents at Brent B Tinnin Manor.
Complaint Details
The complaint investigation was triggered by allegations of abuse between two residents. The investigation found that the facility failed to thoroughly investigate and report the abuse allegations. The complaint was substantiated based on record reviews and interviews.
Findings
The facility failed to thoroughly investigate resident-to-resident abuse allegations and did not report the results of investigations to the administrator or other officials as required. Interviews and record reviews showed inadequate investigation and reporting of an incident involving two residents.
Deficiencies (2)
F610: The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving two residents and did not report investigation results to the administrator or other officials within required timeframes.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property as required by state regulations.
Report Facts
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Failed to report allegations of abuse and was involved in the incident investigation |
| RN B | Registered Nurse | Received call from Administrator and provided information about the incident |
| Director of Nurses | Notified and called the Administrator about the verbal altercation | |
| Administrator | Responsible for overseeing investigation and was contacted during the incident |
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
Annual Inspection
Census: 51
Deficiencies: 8
Date: Mar 13, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations at Brent B Tinnin Manor nursing facility.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, baseline care planning, quality of care, wound care, medication administration, infection control, and environmental safety. Several residents' medical records and care plans lacked proper documentation and adherence to physician orders.
Deficiencies (8)
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for multiple residents and did not provide a policy related to MDS accuracy.
F655 Baseline Care Plan. The facility failed to implement an accurate baseline care plan upon admission and did not ensure residents or representatives received a written summary.
F684 Quality of Care. The facility failed to follow physician orders for wound care and medication administration for multiple residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to ensure proper placement and care of Foley catheters and drainage bags, and lacked a policy for catheter care.
F758 Free from Unnecessary Psychotropic Medications/PRN Use. The facility failed to implement recommended gradual dose reductions for psychotropic drugs for one resident.
F883 Influenza and Pneumococcal Immunizations. The facility failed to document accurate immunization status and provide education for multiple residents.
F887 COVID-19 Immunization. The facility failed to develop and implement policies ensuring COVID-19 vaccination education, documentation, and administration for residents and staff.
F921 Safe/Functional/Sanitary/Comfortable Environment. The facility failed to maintain a safe environment by not removing items from overbed light fixtures that could affect residents and staff.
Report Facts
Facility census: 51
Number of sampled residents: 13
Number of residents reviewed for immunization: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Craig | RN LNHA | Administrator signing plan of correction |
Inspection Report
Life Safety
Census: 51
Deficiencies: 6
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure doors to hazardous areas had self-closing devices, maintain illumination of means of egress, and adequately secure oxygen cylinders. These deficiencies had the potential to affect all residents and staff.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices appropriately installed as required by NFPA standards.
K281 Illumination of Means of Egress: The facility failed to maintain illumination of means of egress in accordance with NFPA 101, affecting emergency lighting at rear hall exterior exits.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to adequately secure one oxygen cylinder in accordance with NFPA 99.
A2010 Oxygen Storage: Oxygen storage was not in accordance with NFPA 99; safety caps and cylinder support requirements were not met.
A2050 Emergency Lighting: The facility lacked emergency lighting of sufficient intensity to provide safety for residents and others using exits, stairways, and corridors.
A2055 Door Devices: The facility did not have attached self-closing devices on all doors providing separation between floors as required.
Report Facts
Facility census: 51
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 |
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 7
Date: Aug 17, 2022
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident care, infection control, medication administration, and other quality standards at Brent B Tinnin Manor.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, professional standards of care, quality of care, free of accident hazards, infection prevention and control, antibiotic stewardship, and immunizations. Deficiencies were documented with specific resident cases and facility policy failures.
Deficiencies (7)
F641 Accuracy of Assessments: The facility failed to accurately code the Minimum Data Set (MDS) for one resident, incorrectly coding use of physical restraints and pressure ulcers.
F658 Services Provided Meet Professional Standards: The facility failed to follow a physician's order to discontinue medication for one resident, resulting in continued administration after the order date.
F684 Quality of Care: The facility failed to complete and sign the coordinated plan of care and did not have legal selection of hospice for one resident receiving hospice services.
F689 Free of Accident Hazards: The facility failed to secure chemicals behind locked doors and failed to use a gait belt when repositioning a resident, creating safety hazards.
F880 Infection Prevention & Control: The facility failed to ensure staff followed infection control policies including mask wearing, social distancing, and annual review of the infection control program.
F881 Antibiotic Stewardship Program: The facility failed to provide documentation of an antibiotic stewardship program and its annual review.
F883 Influenza and Pneumococcal Immunizations: The facility failed to provide education, documentation of consent/refusal, and proper administration of pneumococcal vaccines for several residents.
Report Facts
Facility census: 32
Number of sampled residents: 12
Number of residents affected by pneumococcal vaccine deficiency: 3
Number of residents receiving antibiotics: 2
Plan of correction completion date: Sep 30, 2022
Inspection Report
Life Safety
Census: 32
Deficiencies: 6
Date: Aug 17, 2022
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at Brent B Tinnin Manor.
Findings
The facility failed to maintain doors with self-closing devices, discharge from exits, illumination of means of egress, hazardous areas enclosure, sprinkler system maintenance, and electrical equipment safety. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K223 Doors with Self-Closing Devices: The facility failed to maintain doors in the intended manner of design, including removal of self-closure devices. The door to the laundry room was repaired to include a self-closure device.
K271 Discharge from Exits: The facility failed to maintain required exit egress pathways, including the rear resident smoking patio lacking a safe pathway. A new pathway was planned for construction.
K281 Illumination of Means of Egress: The facility failed to maintain emergency egress lighting, with solar powered lights showing water and rust residue and no testing feature. Replacement with battery-operated lights was planned.
K321 Hazardous Areas - Enclosure: The facility failed to maintain hazardous areas with required fire barriers and self-closing doors, including holes in ceilings allowing attic access and unsealed mechanical room holes.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler inspections, with the annual inspection overdue since February 2022.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to limit use of temporary wiring, with power strips plugged into non-medical grade power strips and a 3-way splitter in use.
Report Facts
Facility census: 32
Date survey completed: Aug 17, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on 12/29/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation was completed and found no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Sep 30, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property and abuse allegations at Brent B Tinnin Manor.
Complaint Details
Complaint #173077 regarding misappropriation of resident funds by a staff member was substantiated based on interviews, record reviews, and ATM video evidence.
Findings
The facility failed to protect a resident from misappropriation of funds by a staff member who used the resident's debit card for unauthorized cash withdrawals totaling $606.00. The investigation included interviews, record reviews, and ATM video evidence confirming the staff member's actions.
Deficiencies (2)
F602: The facility failed to protect a resident from misappropriation of funds by a staff member who used the resident's debit card for unauthorized cash withdrawals totaling $606.00. The employee is subject to termination and retraining on abuse and neglect policies will be provided.
A8022: The facility did not ensure each resident was free from abuse, including verbal, physical, and financial abuse, as evidenced by the misappropriation incident documented under F602.
Report Facts
Facility census: 38
Misappropriated funds amount: 606
ATM withdrawal amounts: 503
ATM withdrawal amounts: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Koreen Ellsworth | Administrator | Signed the statement of deficiencies and plan of correction |
| Employee A | Interviewed regarding the misappropriation of resident funds | |
| Certified Nurse Assistant B | CNA | Identified as the staff member who made unauthorized cash withdrawals using the resident's debit card |
| Director of Nurses | DON | Interviewed about the incident and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on 9/2/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation was conducted alongside the COVID-19 Focused Infection Control Survey. No deficiencies were cited, indicating compliance.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this onsite visit.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess the facility's compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 4
Date: Dec 19, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Brent B Tinnin Manor following a survey completed on 12/19/2019. The visit was conducted to identify regulatory deficiencies and require corrective actions.
Findings
The facility was found deficient in multiple areas including failure to develop and implement abuse/neglect policies, failure to accurately code Minimum Data Set assessments, failure to develop comprehensive care plans, and failure to provide adequate incontinent care. Several residents' records and care practices were reviewed and found lacking.
Deficiencies (4)
F607: The facility failed to develop and implement written policies to prohibit abuse, neglect, and exploitation, and failed to complete required background checks for new hires. The facility census was 27.
F641: The facility failed to accurately code the Minimum Data Set (MDS) assessments for five of twelve sampled residents, resulting in inaccurate reflection of residents' status.
F656: The facility failed to implement individualized comprehensive care plans to meet the highest practicable physical, mental, and psychosocial well-being for two residents out of twelve sampled residents. The facility census was 27.
F677: The facility failed to provide adequate incontinent care for three residents out of twelve sampled residents. The facility census was 27.
Report Facts
Facility census: 27
Sampled residents: 12
Residents with inaccurate MDS coding: 5
Residents with inadequate care plans: 2
Residents with inadequate incontinent care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Pleasant | Administrator | Named in interview regarding background check policies and care practices |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 4
Date: Dec 19, 2019
Visit Reason
The document is a plan of correction submitted following a life safety code survey conducted on 2019-12-19 at Brent B Tinnin Manor.
Findings
The facility failed to maintain functioning exit signage and failed to keep smoking areas free of combustible trash, potentially affecting all residents and staff. The facility census was 27 at the time of the survey.
Deficiencies (4)
K293 Exit signage was not maintained with continuous illumination as required by NFPA 101. The dining exit sign did not function when tested on 12-17-19.
K741 Smoking regulations were not met as the smoking courtyard urns contained combustible trash mixed with cigarette butts. The facility failed to maintain smoking areas free of combustible trash.
A2049 Facilities failed to maintain all exit and directional signs clearly legible and electrically illuminated at all times by acceptable means such as emergency lighting when lighting fails.
A2057 Designated smoking areas lacked ashtrays of noncombustible material and safe design. Ashtrays were not properly disposed of in receptacles made of noncombustible material.
Report Facts
Facility census: 27
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 12
Date: Nov 9, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including advance directives, Medicaid/Medicare coverage notices, notice requirements before transfer/discharge, baseline care plans, comprehensive care plans, drug regimen review, food safety, infection control, and discharge summaries. Several residents' records and facility policies were not in compliance with regulatory requirements.
Deficiencies (12)
F578 Advance Directives: The facility failed to ensure accuracy of a resident's advance directive regarding resuscitation status for one resident.
F582 Medicaid/Medicare Coverage: The facility failed to issue required Medicare Non-Coverage and Skilled Nursing Facility Advanced Beneficiary Notices for three residents.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents or representatives in writing of transfers or discharges for four residents.
F625 Notice of Bed Hold Policy: The facility failed to notify residents or representatives in writing of the bed hold policy at the time of transfer for four residents.
F655 Baseline Care Plan: The facility failed to develop baseline care plans within 48 hours of admission for two residents.
F656 Comprehensive Care Plan: The facility failed to implement comprehensive care plans with specific interventions tailored to individual needs for two residents.
F657 Care Plan Timing and Revision: The facility failed to update and revise care plans with specific interventions for two residents.
F700 Bed Rails: The facility failed to obtain informed consent, physician orders, and assessments for use of bed rails for one resident.
F756 Drug Regimen Review: The facility failed to ensure physician response to pharmacist recommendations for three residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to store and distribute food under sanitary conditions, increasing risk of food-borne illness affecting four residents.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program, affecting one resident and one outside resident.
F881 Antibiotic Stewardship Program: The facility failed to establish an antibiotic stewardship program and monitor antibiotic use.
Report Facts
Facility census: 30
Residents sampled: 12
Residents affected by food safety deficiency: 4
Residents affected by infection control deficiency: 1
Residents affected by antibiotic stewardship deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda Johnson | Administrator | Named in plan of correction and signature on multiple pages |
Inspection Report
Life Safety
Census: 30
Deficiencies: 14
Date: Nov 9, 2018
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and related requirements at Brent B Tinnin Manor.
Findings
The facility was found deficient in multiple life safety code areas including the use of microwaves in resident rooms, annual door inspections, emergency lighting, exit signage, fire suppression in the kitchen, sprinkler system maintenance, smoking regulations, combustible decorations, portable space heaters, electrical receptacle testing, and storage of oxygen cylinders. The facility census was consistently noted as 30 residents.
Deficiencies (14)
K100: The facility does not prohibit the use of microwave cooking devices in resident rooms, creating a fire hazard. Microwaves were observed plugged into rooms #52 and #54.
K222: The facility failed to complete required annual door inspections, potentially affecting all residents and staff. Maintenance supervisor confirmed no annual door inspection is performed.
K281: The facility failed to maintain emergency egress lighting and exit signage, affecting all residents and staff. Observations showed insufficient illumination and missing exit signs.
K293: The facility failed to provide adequate exit signage, potentially affecting all residents and staff. Observations showed missing visible exit signs in Sassafras and Dogwood halls.
K324: The facility failed to provide adequate fire suppression coverage in the kitchen, potentially affecting all residents and staff. Observed missing nozzle to suppress fire from fryers.
K353: The facility failed to maintain consistent sprinkler coverage, potentially affecting all residents and staff. Observed sprinkler heads showed signs of damage and improper orientation.
K363: The facility failed to maintain corridor doors free from impediments, affecting all residents and staff. Observed doors with gaps, door stops, trash cans blocking doors, and doors not closing properly.
K372: The facility failed to maintain smoke barrier walls free from penetrations, affecting all residents and staff. Observed unsealed roof deck seams at smoke barrier walls.
K741: The facility failed to maintain smoking areas in accordance with NFPA regulations, affecting all residents and staff. Observed smoking room door open and lighters chained to a bench.
K753: The facility failed to prohibit the use of combustible decorations, creating a fire hazard. Observed candles with wicks on display in the front area.
K781: The facility failed to be free of portable space heaters, potentially affecting all residents and staff. Observed electric fireplace and space heaters present.
K912: The facility failed to provide adequate testing and maintenance of electrical receptacles in resident rooms, potentially affecting all residents and staff. Maintenance supervisor confirmed no receptacle inspections.
K920: The facility failed to prohibit improper use of power strips and extension cords, creating electrical hazards. Observed multiple power strips with numerous cords in various areas.
K923: The facility failed to maintain separate storage of empty and full oxygen cylinders, potentially affecting all residents and staff. Observed mixed storage of full and empty cylinders without proper separation.
Report Facts
Facility census: 30
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