Cycle 1
Health 2025-03-19 · Fire 2025-03-19
16 health deficiencies
Top issue: Infection Control (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Ellington, MO
Brent B Tinnin Manor
1-star overall rating with 3-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
220 Euel Polk Drive, Ellington, MO
(573) 663-2545
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Circle B Enterprises
Operator or chain grouping
Approved since
1991-10-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.37
Licensed practical nurse staffing
Aide hours / resident day
2.17
Nurse aide staffing
Weekend hours
2.31
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.5 |
2.3
3.2 pts worse
|
1.8
3.7 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
84.8%
10.8 pts better
|
93.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.0% |
90.9%
7.9 pts worse
|
95.5%
12.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
4.1%
1.4 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.3% |
14.7%
4.4 pts better
|
11.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.9% |
5.5%
4.4 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
25.3%
0.6 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 54.7% |
25.0%
29.7 pts worse
|
16.7%
38 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.5% |
20.3%
13.2 pts worse
|
16.3%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.3% |
19.8%
10.5 pts worse
|
14.9%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.7% |
1.4%
4.3 pts worse
|
1.0%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.6%
1.5 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
18.1%
12 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.0% |
5.0%
4 pts worse
|
5.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.0% |
66.4%
7.6 pts better
|
81.7%
7.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.0% |
2.2%
5.8 pts worse
|
1.6%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 10.0% |
63.5%
53.5 pts worse
|
79.7%
69.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-13 · Fire 2024-03-13
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-03-19
F · Potential for more than minimal harm
2025-03-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-03-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-19
F · Potential for more than minimal harm
2024-03-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-18
F · Potential for more than minimal harm
2024-03-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-18
F · Potential for more than minimal harm
2024-03-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-18
F · Potential for more than minimal harm
2022-08-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-30
F · Potential for more than minimal harm
2022-08-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-19
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-19
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-19
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-24
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-11-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-03-13
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-04-18
D · Potential for more than minimal harm
2022-08-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-09-30
Penalties and ownership
What sits behind the stars
Ownership
Circle B Enterprises Holding Company Inc
5% Or Greater Direct Ownership Interest · Organization
Agh1 LLC
Operational/Managerial Control · Organization
Beaird, Todd
Corporate Officer · Individual
Bedell, Donald
Operational/Managerial Control · Individual
Bedell, Donald
Corporate Director · Individual
Bedell, Donald
Corporate Officer · Individual
Pierce, David
Operational/Managerial Control · Individual
Rubi, Rodney
Operational/Managerial Control · Individual
Sovereign Healthcare Group LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Clark's Mountain Nursing Center
Piedmont, MO
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Riverways Manor
Van Buren, MO
3-star overall rating with 4-star inspections with 7 recent health deficiencies
#3
Greenville Health Care Center
Greenville, MO
3-star overall rating with 4-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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