Brent B Tinnin Manor

Inspectors wroteBased on interview and record review, the facility failed to implement a Quality Assurance and Performance Improvement Plan (QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.) The facility census was 40. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The owner and/or governing board of the facility is ultimately responsible for the QAPI program; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility census was 40. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance and Improvement Program (QAA/QAPI - a written plan containing the process that will guide the facility's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved) committee meetings with the required members. The facility census was 40. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, dated February 2020, showed: - The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents; - The owner and/or governing board of the facility is ultimately responsible for the QAPI program; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain the surety bond (a purchased bond for the security of residents' personal funds) for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months from November 2023 through October 2024. The facility's census was 40. Review of the facility's policy titled, Surety Bond, dated March 2021, showed: - A surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of the resident's funds that the facility holds, accounts for, safeguards, and manages; - This facility holds a surety bond to guarantee the protection of the residents' funds managed by the facility on behalf of its residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to properly document notification and obtain a signature of the resident or legal representative for three residents (Residents #2, #36, and #51) out of three sampled residents on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms prior to the facility discharging the resident from Medicare services. The census was 40. Review of facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to complete Criminal Background Checks (CBC) for four employees (Employees A, B, C, and D) and to check the Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused, neglected, and/or misappropriated funds or property from a resident) prior to the hire date for two employees (Employees A and B) out of five sampled employees . The facility census was 40. Review of the facility's policy titled, Background Screening Investigations, dated March 2019, showed: - Background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors should be conducted. Background and criminal checks are initiated within two days of an offer of employment and completed prior to employment. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written copy of the notice of transfer or discharge to the resident and/or the resident's responsible party for five residents (Residents #5, #9, #34, #36, and #45) out of five sampled residents. The facility census was 40. Review of the facility's policy titled, Transfer or Discharge, dated October 2022, showed: - Transfer and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside the facility; - When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, not discharges, because the resident's return is generally expected; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of the transfer to the hospital for six residents (Residents #2, #5, #9, #34, #36, and #45) out of six sampled residents. The facility's census was 40. Review of the facility's policy titled, Bed Holds and Returns, dated October 2022, showed: - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which addresses holding or reserving a resident's bed during periods of absence at least twice (included in the admission packet, and at the time of transfer, if an emergency, within 24 hours.) 1. Review of Resident #2's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) assessment within 14 days of admission to hospice services for one resident (Resident #4) out of one sampled resident. The facility census was 40. The facility did not provide a policy regarding the completion of significant change MDS assessments. 1. Review of Resident #4's medical record showed: - admitted to hospice services on 02/28/25; - No significant change MDS dated on or after 02/28/25; - The facility failed to complete a significant change MDS within 14 days of the resident's admission to hospice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #4) had a completed hospice (palliative care for the terminally ill with a life expectancy of six months or less) coordinated plan of care, received the needed care and services in accordance with professional standards of practice by not turning and repositioning, and to follow physician's orders for daily wound care treatments and a wound culture out of one sampled resident receiving hospice services, positioning due to impairment, and wound care and culture. The facility also failed to monitor a valproic acid (an anticonvulsant medication) level for one resident (Resident #3) out of one sampled resident. The facility census was 40. Review of the facility's policy titled, Hospice Program, revised July 2017, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for use of a continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open during sleep) and failed to follow physician's order for continuous oxygen for one resident (Resident #4) out of three sampled residents. The facility's census was 40. Review of the facility's policy titled, Oxygen Administrator, revised October 2002, showed: - Verify that there is a physician's order. The facility did not provide a policy regarding CPAP use. 1. Review of Resident #4's medical record showed: - admission date of 02/10/25; - Diagnoses of protein calorie malnutrition and heart failure (heart doesn't pump blood like it should). Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four nurse aides (NAs) (NA B, NA D, NA F and NA G) out of four sampled NAs, completed a nurse aide training program within four months of his/her employment at the facility. The facility's census was 40. Review of the facility's policy titled, Nurse Aide Orientation, revised October 2017, showed: - All newly hired nurse aides must attend an orientation program within their first five days of employment; - The orientation program is not a part of the 75 hour training program and must be completed before the nurse aide begins the training course; - The policy didn't address the time frame the NA must complete the nurse aide training. 1. Review of NA B's personnel file showed: - A hire date of 03/16/24; - NA B completed the nurse aide program, but did not test; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #4) out of one sampled resident, wound care for three residents (Residents #4, #19, and #33) out of three sampled residents, and incontinent care for two residents (Resident #4 and #34) out of three sampled residents. The facility failed to ensure proper enhanced barrier precautions (EBP) were utilized for three residents (Residents #4, #19, and #33) and to have dedicated disposable supply items for two residents (Residents #4 and #34) out of three sampled residents on EBP. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program to include an infection surveillance program and antibiotic use protocols. The facility failed to identify an appropriate indication for use of an antibiotic for one resident (Resident #19) out of one sampled resident who was currently being treated with an antibiotic. This deficient practice had the potential to affect all residents in the facility. The facility census was 40. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed: - Antibiotics will be prescribed and administered to the residents under the guidance and the facility's Antibiotic Stewardship Program; - The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to document pertinent education provided to the resident or the resident's representative regarding benefits, side effects, or warnings of the influenza (a viral respiratory infection) vaccine for four residents (Residents #2, #4, #25, and #34) and for the pneumococcal (an infectious lung disease) vaccine for three residents (Residents #4, #25, and #34) and administered the pneumococcal vaccine to one resident (Resident #2) who refused the vaccine out of five sampled residents. The facility's census was 40. Review of the facility's policy titled, Influenza Vaccine, revised March 2022, showed: - All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the COVID-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Residents #2, #4 and #34) out of five sampled residents. The facility's census was 40. Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Vaccination of Residents, revised May 2023, showed: - Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated; - COVID-19 vaccine education, documentation, and reporting are overseen by the infection preventionist (IP) and coordinated by his or her designee; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident #1) was free of misappropriation of his/her property when the former Administrator (FADM) used the resident's bank debit card to remove money for his/her own personal use. The total misappropriated amount exceeds $12,000. The census was 44. The administration was notified on 03/05/2025 of the Past Non-Compliance which occurred between November of 2024 and December of 2024. On 01/09/2025 the facility, upon notification of missing funds, started an investigation. On 01/15/2025 the facility terminated the FADM and started in-servicing on the facility's policy and procedures on misappropriation. The police were notified on 01/09/2025. The non-compliance was corrected on 01/09/2025. Review of the facility's Abuse Prevention Program dated March 2021, showed: [...]

Inspectors wroteBased on record review and interview the facility failed to thoroughly investigate a resident to resident abuse allegation for two residents (Residents #1 and #2) out of a sample of four residents when Licensed Practical Nurse (LPN) A failed to report allegations of Resident #2 hitting Resident #1 to the Administrator for investigation. This deficient practice had the potential to effect all residents. The facility census was 52. Review of the Facility's Abuse and Neglect Policy dated September 2021 showed: - The Facility will not tolerate verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, or misappropriation of resident property, by employees, family members, visitors, or other residents; - Establish an atmosphere conducive to reporting any indications of abuse, neglect, mistreatment, or misappropriation of resident property; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, for three residents (Residents #1, #25 and #36) out of 13 sampled residents. The facility census was 51. The facility did not provide a policy related to the accuracy of the MDS assessments. 1. Review of Resident #1's medical record showed: - An admission date of 03/30/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions and failed to ensure the resident and/or the resident's representative received a written summary of the baseline care plan for one resident (Resident #14) out of one sampled resident. The facility census was 51. Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, showed: - A baseline plan of care is to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; - The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Resident #1, #26, and #34) out of 13 sampled residents. The facility census was 51. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #1's Physician's Order Sheet (POS), dated January 2024, showed: - Date of admission [DATE]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure placement of the Foley catheter (a tube inserted into the bladder to drain urine) tubing and drainage bags for two residents (Resident #14 and 42) out of four sampled residents. The facility census was 51. Review of the facility's policy titled, Indwelling Catheter Care, undated, showed: - Secure catheter tubing using a leg strap to reduce the tension; - Coil the drainage bag tubing and secure it to the bed to prevent dependent loops; - Ensure drainage bag is covered for resident dignity. The facility did not provide a policy in regards to Foley catheter placement. 1. Review of Resident #14's medical record showed: - admission date of 02/21/24; - Diagnosis of urinary retention (an inability to empty the bladder of urine); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a recommended gradual dose reductions (GDR) for one resident (Resident #12) out of five sampled residents. The facility census was 51. Review of the facility's policy titled, Residents Drug Regimen Review, undated, showed: - The consultant pharmacist shall review the drug regiment of each resident at least monthly or more often if necessary; - The consultant pharmacist will report any irregularities noted in writing to the Director of Nursing (DON), the attending physician, and the facility's medical director; - The attending physician must document in the resident's medical record that the irregularity has been reviewed and what, if any, action has been taken to address it; [...]

Inspectors wroteBased on interview and record review, the facility failed to document accurate immunization status, provide information and education to each resident or the resident's representative of the influenza vaccine (a vaccine used to protect against influenza (a viral respiratory infection)), pneumococcal vaccines (a vaccine used to protect against pneumonia bacteria) for four residents (Resident #25, #26, #36, and #45) out of five sampled residents. The facility's census was 51. Review of the facility's policy titled, Influenza Vaccine, revised March 2022, showed: - All residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Coronavirus Disease (COVID-19) (a respiratory disease caused by SARS-CoV-2) vaccination education and declinations were documented in the medical record for four residents (Resident #25, #36, #45, and #203) out of five sampled residents reviewed for immunization documentation. The facility census was 51. Review of the facility's policy titled, COVID-19 - Vaccination of Residents, Revised May 2023, showed: - Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated; - COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee. The individual who coordinates these responsibilities in the facility is: the Director of Nursing (DON); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of overbed light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 51. The facility did not provide a policy. 1. Observation on 03/13/24 at 3:49 P.M., of room [ROOM NUMBER] showed four figurines on top of the light fixture above the bed by the door. 2. Observation on 03/13/24 at 3:50 P.M., of room [ROOM NUMBER] showed one figurine and one stuffed animal on top of the light fixture above the bed by the window. 3. Observation on 03/13/24 at 3:52 P.M., of room [ROOM NUMBER] showed: - Four stuffed animals, two figurines, one flower, and two plaques on top of the light fixture above the bed by the door; - One 8 inch (in.) x 11 in. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for one resident (Resident #19) out of 12 sampled residents. The facility census was 32. 1. Record review of Resident #19's Quarterly MDS, dated [DATE], showed: - The resident with two Stage 2 pressure ulcers (a partial-thickness skin loss into but no deeper than the dermis); - The resident with two bed rails used daily as physical restraints (anything the resident cannot remove easily and restricts freedom of movement or normal access to one's body). Record review of the resident's weekly skin assessment dated [DATE], showed: - Did not address any Stage 2 pressure ulcers. Observation of the resident on 8/15/22 at 3:40 P.M., showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order for one resident (Resident #6) out of 12 sampled residents. The facility census was 32. Record review of the facility's Administering Medications policy, revised 4/19, showed: - Did not address to follow physician's orders. Record review of Resident #6's Physician Order Sheets, (POS), dated 5/16/22 - 6/15/22, showed: - An order for Apixaban (a medicine used to prevent blood clots) five milligrams (mg) twice a day. Record review of the resident's POS, dated 5/18/22, showed: - An order to discontinue the resident's Apixaban. Record review of the resident's Medication Administration Records (MAR) showed: - For 5/16/22 - 6/15/22, Apixaban given twice daily on 5/18/22 - 6/15/22; - For 6/16/22 - 7/15/22, Apixaban given twice daily on 6/16/22 - 6/26/22; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and sign the coordinated plan of care and to have the legal selection of hospice available for review for one resident (Resident #6) out of one sampled resident. The facility census was 32. Record review of the facility's Hospice Program policy, revised 7/17, showed: - The facility with an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so; - In general, the responsibility of the hospice will be to manage the resident's care as it relates to the terminal illness and related conditions, to include, determining the appropriate hospice plan of care, to change the level of services provided when deemed appropriate, to provide medical direction with nursing and clinical management of the terminal illness; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all chemicals were secured behind locked doors in the residents' shower rooms. The facility also failed to use a gait belt to reposition one resident (Resident #1) out of 12 sampled residents. The facility census was 32. 1. Observation of the residents' shower room on Sassafras Hall on 8/16/22 from 10:04 A.M. until 12:14 P.M., showed: - The cabinet door unlocked; - A half full 24 ounce spray bottle of disinfectant solution within reach of the residents on the bottom shelf; - Five safety razors in the unlocked cabinet; - One resident walked back and forth past the propped open shower room door to go to his/her room. 2. Observations on 8/16/22 from 11:27 A.M., until 12:17 P.M., of the shower room on Dogwood Lane Hall, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were following appropriate source control in accordance with national standards and per the facility's policy and procedures when Housekeeper D did not wear a face mask or social distance from residents and other other staff. Additionally, the facility failed to ensure the Infection Prevention Control Program (IPCP) was reviewed and updated annually. These practices had the potential to affect all residents in the facility. The census was 32. 1. Record review of the Centers for Disease Control and Prevention (CDC) guidelines for source control face coverings, updated on 2/2/22, showed: - Source control (a face covering) and physical distance (when feasible and will not interfere with provision of care) recommended for everyone in a healthcare setting. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of the Antibiotic Stewardship Program and its policies were reviewed annually. This had the potential to affect all residents in the facility. The census was 32. Record review of the Antibiotic Stewardship binder showed: - No documentation of the program and policies reviewed in the last year. Record review of the facility's Census and Conditions of Residents, dated 8/14/22, showed two residents received antibiotics. During an interview on 8/17/22 at 1:30 P.M., the Administrator in Training said he did not know the Antibiotic Stewardship Program and policies needed to be reviewed annually and documented as reviewed. He said they had had several administrator changes in the past year and did not realize this had not been done.

Inspectors wroteBased on interview and record review, the facility failed to provide information and education to each resident or the resident's representative for the pneumococcal vaccines, and to ensure the second dose of the vaccine is offered and given. This affected three residents (Resident #6, #27 and #29) out of five sampled residents. This deficient practice had the potential to affect all residents. The facility census was 32. Record review of the facility's Pneumococcal Vaccine policy, revised 2/22, showed: - Prior to or upon admission, residents are assess for eligibility to receive the pneumococcal vaccine series and when indicated, are offered the vaccine services within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated; [...]