Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brent B Tinnin Manor during CMS and state inspections, most recent first.
The facility did not implement a QAPI Plan as required by their policy, which mandates a data-driven program to improve care outcomes and residents' quality of life. The Administrator, new to the role, confirmed that the program was not operational despite having the necessary policy and procedures in place.
The facility did not implement its QAA/QAPI program, failing to develop and document a plan of action to address quality deficiencies. The Administrator admitted the program was not operational, and the DON was unaware of PIPs documentation. This affected all 40 residents.
The facility did not conduct the required quarterly QAA/QAPI meetings with the necessary members. The policy outlined the need for a data-driven QAPI program, but it lacked details on required committee members. The Administrator, who began in January 2025, confirmed that the program was not yet operational, resulting in no committee meetings being held.
The facility failed to maintain a surety bond sufficient to cover residents' personal funds, as required by policy. The bond amount was $51,000, while the average monthly balance of residents' funds required a bond of at least $57,000. The Administrator noted that previous misappropriation of funds led to incorrect accounts, contributing to this deficiency.
The facility failed to document and obtain signatures for Medicare Non-Coverage Notices for three residents discharged from skilled services. The residents were not properly informed of potential non-coverage and financial liability, as required by facility policy.
The facility failed to conduct Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks prior to hiring four employees, contrary to their policies. Interviews confirmed that these checks should be completed before employment, but records showed they were either done late or not documented.
The facility failed to provide written notices of transfer or discharge to residents and/or their responsible parties, as required by policy. This deficiency was identified for five residents who were transferred to the hospital without documented notifications. The Administrator acknowledged the expectation for such notices to be given.
The facility failed to provide written information about the bed hold policy to residents or their representatives during hospital transfers. This issue affected six residents, with no documentation of the required notifications in their medical records, despite multiple hospital transfers.
A facility failed to complete a significant change MDS assessment within 14 days for a resident admitted to hospice services. Despite acknowledgment from the Administrator and MDS Coordinator that such assessments should be completed within 14 days of a significant change, the facility lacked a policy to ensure this was done, resulting in the deficiency.
A facility failed to provide a coordinated hospice care plan and necessary care for a resident, including turning, repositioning, and wound care. Another resident on valproic acid for epilepsy lacked monitoring of medication levels, with no recent lab results to ensure therapeutic levels. Facility policies on hospice care and lab monitoring were not followed.
A facility failed to obtain a physician's order for a CPAP machine and did not follow the continuous oxygen order for a resident with heart failure and malnutrition. Observations showed inconsistent oxygen use, and interviews with staff confirmed expectations for following physician's orders. The deficiency was identified through observations, interviews, and record reviews.
The facility failed to ensure that four NAs completed their training and certification within four months of hire, as required. Despite completing the training program, the NAs had not yet tested, and the facility's policy did not specify a timeframe for training completion. The Administrator acknowledged the lapse, attributing it to a lack of prioritization by the previous administration.
The facility failed to maintain proper infection control practices during catheter, wound, and incontinent care, with staff not adhering to hand hygiene protocols, failing to use enhanced barrier precautions, and sharing supplies between residents. Additionally, the facility did not correctly screen residents for tuberculosis as required by state regulations.
A facility failed to maintain an effective IPCP, including an antibiotic stewardship program, by not documenting appropriate indications for antibiotic use for a resident. The resident was prescribed doxycycline for a wound infection and Flagyl for diarrhea without necessary lab reports or findings. The DON confirmed the lack of a stool culture for Flagyl, and the Administrator acknowledged the failure to follow standard procedures.
The facility failed to document education and consent for influenza and pneumococcal vaccines for several residents. One resident received a pneumococcal vaccine despite refusing it, and others lacked documentation of education or consent for both vaccines. The facility's policies require documented education and consent, which were not followed.
The facility failed to document COVID-19 vaccination education and administration for three residents, despite their various medical conditions. The facility's policy required offering the vaccine and providing education on its benefits and risks, but there was no record of this being done for these residents. The DON stated that vaccinations were offered on admission, annually, or when available, with education and consent forms provided.
A resident's funds were misappropriated by the former Administrator (FADM) who used the resident's debit card for personal use, resulting in over $12,000 being misappropriated. The resident, who had cognitive impairments, was unaware of the unauthorized transactions. The FADM claimed the withdrawals were to prevent Medicaid from using the funds for the resident's bill, but no records supported this claim. The facility's policies were violated, and the police were notified, with the Prosecuting Attorney planning to prosecute the FADM.
A facility failed to investigate a resident-to-resident abuse allegation when an LPN did not report a physical altercation to the Administrator. A resident with cognitive impairment was hit by another resident after an argument, but the incident was only reported as a verbal altercation. The facility's policy requires reporting and investigating abuse, but the LPN's incomplete report led to a lack of proper investigation.
Failure to Implement QAPI Plan
Penalty
Summary
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) Plan, which is essential for maintaining and improving care and services. The facility's policy, dated February 2020, mandates the development, implementation, and maintenance of a data-driven QAPI program focused on care outcomes and residents' quality of life. The policy also states that the facility's owner or governing board is responsible for the QAPI program, and the plan should be presented annually during the recertification survey. However, the facility did not have an implemented QAPI plan that outlined how they would identify and correct quality deficiencies, track and measure performance, and establish goals and thresholds for performance measurements. During an interview, the Administrator, who started in January 2025, acknowledged that although the facility had the QAPI program shell and policy in place, the program was not yet operational.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. The facility's policy, dated February 2020, required the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and residents' quality of life. However, the facility did not maintain the minimum required documentation for a QAPI plan or Performance Improvement Plans (PIPs). During interviews, the Administrator acknowledged that the QAA/QAPI program was not operational, and the Director of Nursing was unaware of the location of any PIPs documentation. This deficiency had the potential to affect all 40 residents in the facility.
Failure to Conduct Required QAA/QAPI Meetings
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) and Quality Assurance and Improvement Program (QAPI) committee meetings with the required members. The facility's policy, dated February 2020, outlined the development and maintenance of a data-driven QAPI program focused on care outcomes and quality of life for residents. The policy stated that the QAPI committee should meet monthly to review reports and monitor activities, but it did not specify the required committee members. Upon review, there was no documentation of the facility holding the minimum required quarterly QAA/QAPI meetings with the necessary members. During an interview, the Administrator, who started in January 2025, acknowledged that the QAA/QAPI program was not yet operational, and therefore, no committee meetings had been conducted.
Failure to Maintain Adequate Surety Bond for Residents' Funds
Penalty
Summary
The facility failed to maintain a surety bond for at least one and one-half times the average monthly balance of the residents' personal funds for the last 12 consecutive months. The facility's policy on surety bonds, dated March 2021, outlines that a surety bond is an agreement to compensate residents for any loss of funds managed by the facility. However, the policy did not specify how the bond amount should be calculated. The facility's approved bond amount was $51,000, while the average monthly balance of residents' personal funds was $38,481.13. This average, when rounded to the nearest thousand and multiplied by one and one-half, indicated a required bond amount of at least $57,000, which the facility did not meet. During an interview, the Administrator acknowledged that the bond should be sufficient to cover the residents' funds. It was revealed that the previous administration had misappropriated money, leading to incorrect and unreconciled accounts. This mismanagement contributed to the facility's failure to maintain the appropriate surety bond amount, thereby not ensuring the security of residents' personal funds as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly document notification and obtain signatures for three residents regarding the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms. This deficiency was identified for three residents who were discharged from skilled services but remained in the facility or were discharged from the facility. The facility's policy requires that these forms be issued to residents or their representatives to inform them of potential non-coverage by Medicare and their financial liability, but this was not done. Resident #2 and Resident #36 were discharged from skilled services with remaining days in their benefit period and stayed in the facility, yet there was no documentation of the NOMNC and SNF ABN forms being issued. Resident #51 was discharged from skilled services and the facility, but the facility failed to notify the resident or their representative of the change in skilled services, and there was no documentation of the NOMNC form. Interviews with the Administrator and Social Service Designee confirmed the expectation that these forms should be provided with proper notifications and signatures in a timely manner, which did not occur in these cases.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the completion of Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for new hires. Specifically, the facility did not conduct CBCs and EDL checks prior to the hire dates for Employees A and B, and failed to complete CBCs prior to the hire dates for Employees C and D. The facility's policy mandates that these checks be initiated within two days of an employment offer and completed before employment begins. However, the records show that these checks were either completed after the hire date or not documented at all. Interviews with the Human Resources staff and the Administrator confirmed that the CBC and EDL checks should be completed before employment and that EDL checks should be conducted quarterly thereafter. The HR staff, who was new to the position, acknowledged the oversight and was in the process of organizing the necessary documentation. The facility's failure to perform these checks as required by their policies represents a deficiency in their hiring and screening processes, potentially compromising resident safety.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written copy of the notice of transfer or discharge to residents and/or their responsible parties for five residents. This deficiency was identified through interviews and record reviews. The facility's policy on transfer or discharge, dated October 2022, outlines that a notice should be given as soon as practicable before the transfer or discharge, especially in cases where the health and safety of individuals in the facility are endangered or when an immediate transfer is required due to urgent medical needs. However, the facility did not adhere to this policy for the sampled residents. Specifically, the medical records of five residents showed multiple instances of transfers to the hospital without documented written notifications provided to the residents or their responsible parties. These residents were transferred on various dates, and in each case, there was no documentation of the written notification with the reason for the hospital transfer. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should receive a written copy of the notice of transfer or discharge, indicating a lapse in the facility's adherence to its own policy and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to a hospital. This deficiency was identified for six residents out of a sample of six, indicating a systemic issue. The facility's policy, dated October 2022, requires that all residents or their representatives receive written information about the bed hold policy at least twice: once in the admission packet and again at the time of transfer, or within 24 hours if the transfer is an emergency. For each of the six residents, there was no documentation in their medical records that they or their representatives were informed in writing of the bed hold policy at the time of their hospital transfers. These residents experienced multiple transfers to the hospital, yet the facility consistently failed to provide the required written notification. During an interview, the Administrator acknowledged the expectation that residents and/or their representatives should be informed in writing of the bed hold policy before a transfer occurs.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days for a resident who was admitted to hospice services. The resident was admitted to hospice on 02/28/25, but there was no significant change MDS dated on or after this date. During interviews, both the Administrator and the MDS Coordinator acknowledged that a significant change MDS should be completed within 14 days of a significant change, such as admission to hospice. However, the facility did not provide a policy regarding the completion of significant change MDS assessments, leading to this deficiency.
Deficiencies in Hospice and Medication Management
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had a completed coordinated plan of care and received necessary care and services according to professional standards. The resident, who was admitted with diagnoses including protein calorie malnutrition and was at risk for pressure ulcers, had specific orders for turning and repositioning every two hours and daily wound care. However, observations revealed that the resident was left in the same position for extended periods, and wound dressings were not changed daily as ordered. Additionally, the hospice coordinated plan of care did not address the resident's wounds or Foley catheter care. Another resident, who had a diagnosis of epilepsy and was on valproic acid, did not have an order for monitoring valproic acid levels, which is crucial for maintaining therapeutic levels and preventing toxicity. The last documented valproic acid level was from over a year ago, and there was no follow-up to ensure that the levels were checked regularly. The resident's care plan included a focus on maintaining lab values within the therapeutic range, but this was not adhered to, as evidenced by the lack of recent lab results. The facility's policies on hospice care, lab and diagnostic test results, and prevention of pressure ulcers were not followed. The hospice care plan was not updated to reflect the resident's current needs, and there was a failure to monitor and document lab results for medication management. The facility also did not provide a policy regarding ordering labs for medication monitoring, which contributed to the oversight in managing the resident's valproic acid levels.
Failure to Obtain CPAP Order and Follow Oxygen Orders
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine and did not follow the physician's order for continuous oxygen for a resident. The resident, who was admitted with diagnoses of protein calorie malnutrition and heart failure, had an order for oxygen at 2 liters per minute via nasal cannula continuously. However, there was no order for a CPAP machine, and the resident's care plan did not address the use of a CPAP machine or its settings. Observations showed that the resident was not consistently wearing the oxygen as ordered, and the CPAP machine was used without a physician's order. Interviews with staff, including an LPN and the DON, revealed that they expected physician's orders to be followed, including continuous oxygen use and having an order for CPAP use with specified settings. The resident's oxygen saturation was found to be low at one point, and oxygen was then administered, which improved the saturation level. The facility's policy required a physician's order for oxygen administration, but there was no policy provided regarding CPAP use. The deficiency was identified through observations, interviews, and record reviews, indicating a failure to adhere to physician's orders and facility policies.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that four nurse aides (NAs) completed a nurse aide training program within four months of their employment. The facility's policy required newly hired NAs to attend an orientation program within the first five days of employment, but it did not specify a timeframe for completing the nurse aide training. NA B, NA D, NA F, and NA G were all found to have completed the nurse aide program but had not yet tested, exceeding the four-month requirement from their respective hire dates. Interviews with the NAs and the Director of Nursing revealed that the NAs were working in their positions without having completed the necessary certification within the required timeframe. The Administrator acknowledged the expectation for NAs to be certified within four months of hire and noted that the previous administration did not prioritize this requirement, resulting in the current situation where NAs were ready to test but had not yet done so.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during catheter care, wound care, and incontinent care for several residents. Observations revealed that staff did not adhere to hand hygiene protocols, failed to use enhanced barrier precautions (EBP), and shared supplies between residents. For instance, a Certified Nursing Assistant (CNA) did not perform hand hygiene before and after providing catheter care to a resident, and shared wipes between residents without changing gloves or sanitizing hands. Similarly, a Licensed Practical Nurse (LPN) and another CNA did not follow proper hand hygiene and EBP protocols during wound care and incontinent care, leading to potential cross-contamination. The facility also failed to have dedicated disposable supply items for residents on EBP, as observed during care for residents with catheters and wounds. Supplies such as wound cleansers and tape were placed on unsanitized surfaces without a clean barrier and were not cleansed before being returned to the treatment cart. This practice was observed during wound care treatments for multiple residents, where shared supplies were used without proper sanitation, increasing the risk of infection. Additionally, the facility did not correctly screen residents for tuberculosis (TB) as required by state regulations. Medical records showed missing documentation of TB screenings for several residents, including the absence of admission TSTs and annual screenings. Interviews with staff, including the Director of Nursing (DON) and the Administrator, confirmed that the expected infection control practices were not followed, and supplies should not be shared between residents, especially those on EBP.
Failure in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program, which is essential for monitoring antibiotic use and ensuring appropriate indications for their use. The deficiency was identified when the facility did not document an appropriate indication for the use of antibiotics for a resident who was being treated with doxycycline for a wound infection and Flagyl for diarrhea. The facility's policy on antibiotic stewardship, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of the program, but the documentation was incomplete and lacked necessary lab reports or findings. Resident #19 was prescribed doxycycline for a wound infection and Flagyl for diarrhea, but there was no stool culture to justify the use of Flagyl. The resident had been taking Senna, a stool softener, which was stopped after diarrhea developed, and the diarrhea subsequently ceased. The Director of Nursing confirmed that the Flagyl order was given by the medical director without a stool culture, and the hospital records for the wound infection were not obtained. The Administrator acknowledged that the facility should have followed policy and procedures for the IPCP, including obtaining cultures and labs as expected with standard practice.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to document the provision of education regarding the benefits, side effects, or warnings of the influenza and pneumococcal vaccines for several residents. Specifically, four residents did not have documented evidence of receiving pertinent information about the influenza vaccine, and three residents lacked documentation for the pneumococcal vaccine. Additionally, one resident was administered the pneumococcal vaccine despite having refused it. The facility's policies require that residents or their legal representatives receive and acknowledge this information, which was not adhered to in these cases. Resident #2's medical record showed that they were administered the influenza vaccine without documented consent or education, and received the pneumococcal vaccine after refusing it. Resident #4's record lacked documentation of education, consent, or administration for both vaccines. Resident #25's record showed no documentation of education, consent, or administration for both vaccines in 2024 and 2025. Resident #34 was administered the influenza vaccine without documented education or consent, and there was no documentation regarding the pneumococcal vaccine. The Director of Nursing stated that vaccinations were offered with accompanying education and consent forms, but this was not reflected in the records reviewed.
Failure to Document COVID-19 Vaccination Education and Administration
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered, administered, or refused by three residents out of five sampled residents. The facility's policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or fully vaccinated, with education provided regarding the benefits, risks, and potential side effects. However, for Residents #2, #4, and #34, there was no documentation in their medical records indicating that COVID-19 vaccination education was provided, nor was there any record of the vaccine being administered or refused. Resident #2 had multiple diagnoses, including metabolic encephalopathy, COPD, schizophrenia, hypertension, major depressive disorder, panic disorder, anxiety disorder, and hearing loss. Resident #4 had diagnoses of hematogenous osteomyelitis, heart failure, and dementia. Resident #34 had Alzheimer's disease, cerebral infarction, atrial fibrillation, and hypertension. Despite these conditions, there was no documentation of COVID-19 vaccination education or administration for these residents. The Director of Nursing stated that vaccinations were offered on admission, annually, or when provided by the facility, with education and consent forms given to residents or their representatives.
Misappropriation of Resident's Funds by Former Administrator
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property when the former Administrator (FADM) used the resident's bank debit card for personal use, resulting in a misappropriated amount exceeding $12,000. The incident occurred between November and December 2024, and the facility was notified of the missing funds in January 2025. The resident, who had some cognitive loss and diagnoses including Metabolic Encephalopathy, Schizophrenia, and Major Depressive Disorder, was unaware of the unauthorized withdrawals and purchases made using their account. The facility's investigation revealed that the FADM had used the resident's debit card to withdraw cash and make purchases, including medications sent to the FADM's address. The FADM claimed that the withdrawals were made to prevent Medicaid from requiring the funds to be used for the resident's bill, and that the money was given to the former bookkeeper to pay the resident's expenses. However, there were no records of these transactions being applied to the resident's billing or trust account, and the FADM admitted to accidentally using the resident's card for personal purchases. Interviews with the resident and facility staff confirmed that the resident did not give the FADM permission to use the card, and the facility's policies did not allow for such actions. The FADM's actions were not in line with the facility's Abuse Prevention Program and Management of Residents' Personal Funds policy, which emphasize safeguarding residents' funds and obtaining consent for any transactions. The police were notified, and the case was under investigation, with the Prosecuting Attorney intending to prosecute the FADM for the misappropriation.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two residents. A Licensed Practical Nurse (LPN) did not report the physical altercation between the residents to the Administrator for investigation. The facility's policy mandates the reporting and investigation of any abuse allegations, but in this case, the LPN only reported a verbal altercation, despite being informed of the physical nature of the incident by multiple staff members and the residents involved. Resident #1, who has diagnoses of congestive heart failure, anxiety, and schizophrenia, reported being hit by Resident #2 after an argument over the television volume. Resident #1, who is moderately cognitively impaired and requires maximum assistance with personal care, fell out of the wheelchair after being struck. Resident #2, who is cognitively intact and requires minimal assistance with activities of daily living, admitted to hitting Resident #1 and expressed no remorse for the action. Despite these admissions, there was no documentation of an abuse allegation investigation in either resident's medical record. The incident was initially reported as a verbal altercation by the LPN to the Director of Nurses and the Administrator, who was on vacation at the time. The Administrator delegated the investigation to a Registered Nurse (RN), who was informed by the LPN that there were no injuries and only an argument had occurred. As a result, the RN did not conduct a thorough investigation, believing the situation was resolved by relocating Resident #2 to another room. The failure to properly report and investigate the physical altercation represents a deficiency in the facility's adherence to its abuse and neglect policy.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ellington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clark's Mountain Nursing Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Riverways Manor | 16.7 mi | ★★★★★ | 4 | 0 |
| Greenville Health Care Center | 29.1 mi | ★★★★★ | 0 | 0 |
| Baptist Homes Of Arcadia Valley | 30.7 mi | — | 0 | 0 |
| Rock Point Nursing Center | 34.1 mi | ★★★★★ | 11 | 0 |
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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 July 2026) and official state health department websites.