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
Chain footprint
29 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.82
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.31
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
74%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,642
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0.50
Baseline 77.78% · Performance 72.50% · Measure score 0.50 · Achievement 0 · Improvement 0.50
Adjusted total nurse staffing
0
Baseline 3.36 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 37 |
| Staff flu vaccination coverage | 1.75% |
42%
40.2 pts worse
|
Numerator 1 · Denominator 57 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
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 · Adjusted 2.1 · Observed 2.1 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 5.5 · Observed 6.8 · Expected 2.0 · Used in QM five-star |
| 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 · Q1 92.2% · Q2 93.5% · Q3 97.7% · Q4 100.0% · 4Q avg 95.6% |
| 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 · 4Q avg 83.0% |
| 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 · Q1 2.0% · Q2 4.3% · Q3 2.3% · Q4 2.3% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 4.9% · Q2 9.4% · Q3 5.4% · Q4 22.9% · 4Q avg 10.3% |
| 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 · Q1 10.0% · Q2 9.1% · Q3 12.8% · Q4 7.7% · 4Q avg 9.9% |
| 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 · Q1 26.0% · Q2 22.7% · Q3 24.4% · Q4 30.8% · 4Q avg 25.9% |
| 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 · Q1 58.1% · Q2 57.7% · Q3 54.2% · Q4 48.0% · 4Q avg 54.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 20.6% · Q2 34.1% · Q3 40.1% · Q4 39.8% · 4Q avg 33.5% · Used in QM five-star |
| 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 · Q1 28.9% · Q2 32.5% · Q3 25.0% · Q4 34.2% · 4Q avg 30.3% · Used in QM five-star |
| 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 · Q1 10.5% · Q2 6.7% · Q3 3.3% · Q4 1.3% · 4Q avg 5.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 4.9% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 20.2% · Q2 41.6% · Q3 35.1% · Q4 24.8% · 4Q avg 30.1% |
| 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 · Q1 10.6% · Q2 11.5% · Q3 8.5% · Q4 4.7% · 4Q avg 9.0% · Used in QM five-star |
| 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 · Q2 55.0% · Q3 81.8% · 4Q avg 74.0% |
| 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 · 4Q avg 8.0% · Used in QM five-star |
| 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 · 4Q avg 10.0% |
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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