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Maranatha Village, INC

233 East Norton Road, Springfield, MO 65803 · Non profit - Corporation · 120 certified beds · (417) 833-0016 Medicare & Medicaid certified

Call the home — (417) 833-0016 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Apr 2025$16,335 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,335 in federal fines (most recent 2026-05-04)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Urgent care / clinic
733 W Kearney St · (417) 831-7575 · Call to confirm hours
Pharmacy
1140 E Kearney St · (417) 869-5112 · Call to confirm hours
Grocery
742 E Evergreen St
Park
Typically dawn to dusk
Place of worship
3000 N Grant Ave · (213) 447-2986

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%18.1%15.4%better
Long-stay residents who lose too much weight2.4%5.3%5.4%better
Long-stay residents with a catheter left in their bladder1.6%1.1%0.9%worse
Long-stay residents with a urinary tract infection3.7%2.3%2.0%worse
Long-stay residents with depressive symptoms2.8%18.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.3%4.1%3.3%worse
Long-stay residents whose ability to walk worsened18.6%17.4%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.0%25.6%18.9%better
Long-stay residents given the seasonal flu vaccine92.4%90.9%95.3%typical
Long-stay residents with pressure ulcers2.4%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control26.4%17.8%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.7%23.5%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.3%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine29.0%63.5%79.4%worse
Short-stay residents rehospitalized after admission18.0%26.0%22.6%better
Short-stay residents with an outpatient ER visit7.8%13.7%12.0%better
Long-stay hospitalizations per 1,000 resident days1.822.111.67typical
Long-stay outpatient ER visits per 1,000 resident days0.372.331.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 126 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.1%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
69.2%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 69.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 78 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 49% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.1%CMS range 54.3–70.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 8.1–15.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge69.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge56.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge66.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified97.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.9%CMS range 6.6–15.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.711.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.46
RN hours/ resident / day
0.66
LPN hours/ resident / day
2.82
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.20
RN hoursweekends
40.8%
Total nursing turnover
11.1%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 101.7 residents a day — about 85% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.39 hrs/resident/day on weekends vs 4.16 on weekdays — 18% thinner on weekends. RN hours go from 0.56 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2024-04-19)
7
at the previous standard inspection (2021-06-17)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Dcited before2025-06-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed provide care per standards of practice to all residents when staff failed to document timely and complete assessments and monitoring, and failed to notify the physician in a timely fashion for one resident (Resident #1) after the reisdent fell and when the resident began having low blood oxygen readings. The facility census was 102 residents. Review of the facility's policy titled Change in Resident's Condition or Status, revised on 02/2021, showed the following: -The facility promptly notifies the resident, his/her attending physician, and the resident's representative of changes in the resident's medical/mental condition and or status; -The nurse will notify the resident's attending physician or on call physician when there is significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment; -The nurse will record in the resident's medical record information relative to the changes in medical/mental condition/status. Review of the facility's current…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-09 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to protect all residents from misappropriation of property when a facility staff member (Certified Nurse Aide (CNA) A) received multiple checks from one resident's (Resident #1's) checking account after expressing his/her financial need to the resident. The facility census was 101. Review of the facility policy titled, Identifying Exploitation, Theft and Misappropriation of Resident Property, dated April 2021, showed the following: -Exploitation, theft, and misappropriation of resident property are strictly prohibited; -Exploitation means taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats or coercion; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Review of Resident #1's face sheet showed: -admission date of 08/26/23; -Diagnoses included multiple sclerosis (disease that affects the central nervous system and disrupts the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-03 · tag F0622 — isolated
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure documentation was present in the medical record to support any discharge when staff failed to document to the resident's medical records the specific needs the facility could not meet, the attempts the facility made to meet those needs, and the services available at the receiving facility to meet the need, including documentation from the physician, for one resident (Resident #1) who was issued a facility initiated discharge notice. The facility's census was 87. Review of a facility policy titled Transfer or Discharge, Facility-Initiated, revised October 2022, showed the following: -Once admitted to the facility, residents have the right to remain in the facility; -Facility-initiated discharges must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; -A resident will not be discharged unless the discharge is necessary for the resident's welfare and the resident's needs cannot be met in facility; -A resident's declination of treatment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure staff treated all residents in a dignified fashion when one staff member (Licensed Practical Nurse (LPN) B) made rude and degrading comments during a procedure to replace an indwelling (Foley) catheter (sterile tube inserted to drain the bladder) for one resident (Resident #1). A sample of eight residents with catheters was reviewed. The facility census was 94. Review of the facility policy entitled Resident Rights, revised February 2021, showed the following: -Employees shall treat all residents with kindness, respect, and dignity; -All residents of the facility have the right to a dignified existence; -Orientation and in-service training programs are conducted quarterly to assist employees in understanding the residents' rights. Review of the facility policy entitled Dignity, revised February 2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to protect food from possible contamination at all times in accordance with professional standards of practice when staff failed to wear hairnets in the kitchen, failed to store the ice scoop outside of the ice container, and failed to complete proper handwashing during meal service/prep. The facility census was 85. 1. Observations on 04/16/24, from 9:15 A.M. to 10:20 A.M., showed the following: -In the serving kitchen, Certified Nurse Aide (CNA) 1 was inside the kitchen, scooping ice into a cooler without wearing a hairnet. At the time of the observation, food preparation was in process. The Dietary Manager (DM) told CNA 1 that he/she needed to have a hairnet on anytime he/she entered the kitchen. CNA 1 replied I know I do. Observation on 04/19/24, at 10:00 A.M., showed the following: -The Maintenance Director (MD) entered the kitchen without a hairnet, walked past the staff slicing meat for the residents' lunch, and proceeded to the sink. Maintenance Worker (MW) 5 directed the MD to put on a hairnet. The MD…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain their infection prevention program to reduce the likelihood of a legionella (the bacterium which causes legionnaires' disease (a severe form of pneumonia) which can grow in areas with stagnant water) in the water when the facility failed to follow their water management program by not completing the preventative steps outlined and when the facility failed to ensure staff were educated regarding the water management program. The facility census was 85. 1. Review of the facility's policy titled, Water Management Program, undated, showed the following: -Specific measures used to control the introduction and/or spread of Legionella; -The control limits or parameters that are acceptable and that are monitored; -A diagram of where control measures are applied; -A system to monitor control limits and the effectiveness of control measures; -a plan for when control limits are not met and/or control measures are not effective; -Documentation of the program. Review of an undated document, provided by the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-19 · tag F0625 — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the resident and/or responsible party (RP) information regarding a Bed Hold for three residents (Resident #30, #50, and #67) of a sample of three residents reviewed for hospitalizations of 33 sampled residents. The facility census was 85. Review of the facility's policy titled, Bed Hold Policy, undated, showed the following: -The resident and/or responsible party will be held responsible for 75% of the daily room rate should they wish to reserve their room while in the hospital; -The nursing home has an obligation to inform the resident or the responsible person that is paying them to hold a bed is voluntary; -When a resident is transferred to a hospital, the nursing home is required both by federal statute and by federal regulation, to readmit the resident immediately upon the first availability of a bed in a semiprivate room should the resident choose not to do a bed hold. Review of the facility's policy titled, Bed-Holds and Returns, revised…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-19 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to maintain and update comprehensive care plan to ensure their accuracy when staff failed to care plan the use of usage for four residents (Resident #9, #30, #45, and #54) and failed to care plan anticoagulant (medicines that help prevent blood clots) usage for one resident (Resident #75). The facility census was 85. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, and record review, the facility failed to protect the dignity of all residents when the facility failed to respect one resident's (Resident #50) preference to help with nighttime care and when staff failed to protect one resident's (Resident #39) health information from public viewing. A sample of 33 residents was reviewed in a home with a census of 85. Review of the facility's policy titled, Dignity, dated 02/21, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity, and respect at all times; -The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; -Staff protect confidential clinical information. The resident's clinical status or care needs are not openly posted in the resident's room unless…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed provide respiratory care per standards of practice when staff did not have physician orders for oxygen usage for two residents (Residents #37 and #9). A sample of residents was reviewed in a facility with a census of 85. Review of the facility's policy titled, Oxygen Administration, dated October 2010, showed the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Verify there is a physician's order for this procedure; -Review the physician's order or facility protocol for oxygen administration. 1. Review of Resident 37's admission Record located in the Profile tab of the EMR, showed the following: -admission date of 01/23/24; -Diagnoses included of pleural effusion (the buildup of excess fluid between the layers of the pleura outside the lungs), unspecified fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), heart disease and hypertension (high blood pressure). Review of the resident's quarterly Minimum Data Set (MDS…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-04-19 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to accommodate one resident's (Resident #88) known dietary preferences. A sample of 33 residents were reviewed in a home with a census of 85. Review of the facility's policy titled, Resident Food Preferences, revised July 2017, showed the following: -Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team; -Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences; -The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 1. Review of Resident #88's admission Record from the electronic medical record (EMR) Profile tab showed an admission date of 03/25/24. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff ) with an Assessment Reference Date (ARD) of 04/02/24, showed the following: -Diagnoses…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to provide the pneumococcal vaccine as ordered for two residents (Resident #43 and #75) of the seven residents reviewed for immunization out of 33 sampled residents. The facility census was 85. Review of the facility's policy titled, Pneumonia Vaccine, revised March 2022, showed the policy did not address the procedure of who should administer the vaccine when ordered and arrived at the facility. 1. Review of Resident #43's Medication Administration Record (MAR), dated November 2023, from the electronic medical record (EMR) under the Orders tab, showed the following: -The PCV 20 (pneumonia vaccine) was ordered and scheduled to be administered either on 11/21/23 or 11/22/23; -On 11/21/23, at 10:29 A.M., the nurse on duty charted a code 9 which, according to the legend, was Other / See Nurse Note. Review of of the resident's EMR Progress Notes, dated 11/2024, showed a following: -A note, dated 11/08/23, where the Infection Preventionist (IP) documented regarding consent for the vaccine; -Staff did not enter a note dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-06 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to allow all resident the right of self-determination when staff failed to honor the one resident's (Resident #1) wishes to have an ambulance called and blocked the resident from exiting the facility to await an ambulance. The facility census was 93. Review of the facility policy titled Resident Rights, revised February 2021, showed, federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity; -Be free from abuse, neglect, misappropriation of property, and exploitation; -Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptom's; -Self-determination; -Communication with and access to people and services, both inside and outside the facility 1. Review of Resident #1's face sheet showed the following: -admission date of 09/27/22; -Resident listed as his/her own responsible party. Review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-06 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the physician of all changes in condition when staff failed to notify the physician that one resident (Resident #1) verbalized a change in condition and requested to go to the emergency room for evaluation. The facility census was 93. Review of the facility policy titled, Discharging a Resident Without a Physician's Approval, revised October 2012, showed: -A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice; -Should a resident, or his or her representative, request an immediate discharge, the resident's attending physician will be promptly notified; -The order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge; -If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a release of responsibility form.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide all residents with care per standards of practice when staff failed to remove one resident's (Resident #2's) topical dressings, located on the resident's arms, and failed to complete a head to toe skin assessment upon admission to the facility. The facility census was 93. Review of the facility protocol titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, showed the following: -The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; -The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. 1. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] from the hospital. Review of the resident's diagnosis report showed diagnoses included of encephalopathy (a group of conditions…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide all residents with care of pressure ulcers and pressure sore prevention per standards of practice when staff failed to remove preventative pressure dressing for two residents (Resident #2 and #3) and failed to complete a head to toe skin assessment upon admission to the facility for both residents. The facility census was 93. Review of the facility policy titled, Prevention of Pressure Injuries, revised April 2020, showed the following: -The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors; -Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition; -Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior discharge; -Inspect the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure medical records were complete when staff failed to document an assessment and vital signs for one resident (Resident #1) when the resident expressed a change in condition. The facility census was 93. Review of the facility policy titled, Change in a Resident's Condition or Status, revised February 2021, showed the following: -A significant change in the resident's condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, impacts more than one area of the resident's health status, requires interdisciplinary review and/or revision to the care plan, and ultimately is based on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument. -Prior to notifying the physician or healthcare provider, the nurse will make detained observations and gather relevant and pertinent information for the provider; -The nurse will record in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for three residents (Resident #27, #68 and #278) out of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 74. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-06-17 · tag F0602 — failed to protect residents from theft of their belongings — pattern
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to protect four residents (Resident #273, #274, #275, and #276) from misappropriation of medications when narcotic pain medications went missing while in the possession of the facility staff. The facility census was 74. Record review of the facility's Abuse and Neglect Policy and Procedures Reporting Reasonable Suspicion of a Crime, dated 3/1/2017 showed the following information: -Purpose: This policy and procedure is implemented to provide a system to prevent and detect abuse, neglect, exploitation and mistreatment to provide a system of reporting suspected cases of abuse and neglect and to assure thorough investigation and appropriate follow-up action in alleged incidents of abuse, neglect, exploitation and mistreatment; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -If an incident occurs, or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to check criminal background checks (CBC) or Nurse Aide (NA) registry for a Federal Indicator (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term are facility) prior to starting employment and continued resident contact for three staff (Maintenance Staff D, Administration Staff E, and Certified Nursing Assistant (CNA) F) out of ten sampled staff. The facility census was 74. Record review of the facility's undated policy titled, Employee Screening, showed the following information: -It is the policy to undertake background checks of all employees to the fullest extent required and/or permitted by applicable law and available sources and to retain on file applicable records of current employees regarding such investigations; -Check with Missouri nurse assistant registry; -Check Family Care Safety Registry; -Have not been convicted of an offense or otherwise been found under…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property to the state licensing agency (Department of Health and Senior Services - DHSS) within the required time frame of 24 hours. The facility census was 74. Record review of the facility policy, dated 3/1/2017, abuse and neglect policy and procedures reporting reasonable suspicion of a crime, showed the following information: -This policy and procedure is implemented to provide a system to prevent and detect abuse, neglect, exploitation and mistreatment to provide a system of reporting suspected cases of abuse and neglect and to assure thorough investigation and appropriate follow-up action in alleged incidents of abuse, neglect, exploitation and mistreatment; -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent; -The facility must ensure that all alleged violations involving abuse, neglect, exploitation or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to immediately investigate an allegation of misappropriation of medications by Licensed Practical Nurse (LPN) A, failed to take steps to protect residents from further misappropriation during an investigation, and failed to submit the investigation to the state agency (Department of Health and Senior Services) within the required five days after the allegation was made. The facility census was 74. Record review of the facility's policy Abuse and Neglect Policy and Procedures Reporting Reasonable Suspicion of a Crime, dated 3/1/2017, showed the following information: -This policy and procedure is implemented to provide a system to prevent and detect abuse, neglect, exploitation and mistreatment to provide a system of reporting suspected cases of abuse and neglect and to assure thorough investigation and appropriate follow-up action in alleged incidents of abuse, neglect, exploitation and mistreatment; -Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, the facility failed to dispose of expired medications and supplies stored in the 100/200 hall medication storage room and the 300/400 hall medication cart. The facility census was 74. Record review of the facility's Storage of Medications Policy, dated November 2020, showed the following information: -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1. Observation of the 100/200 hall medication storage room on 6/15/2021, at 9:53 A.M., showed the following medications stored for current and future use: -One bottle of oyster shell calcium 500 milligram (mg), with best by date 4/2021; -Fourteen 5 milliliter (ml), 20 gauge x 1 1/2 inch safety syringe, with expiration date 1/2020; -Ten 5 ml syringes, with expiration date 5/2020; -One 5 ml syringe, with expiration date 11/2019; -One bottle of vitamin D3, with expiration date 1/2021; -Twenty…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to give the correct amount of sliding scale insulin (medication used to manage elevated blood glucose (sugar) levels) to one resident (Resident #17) during random medication pass observations. The facility had a census of 38. Record review of the facility's policy, titled Insulin Administration, dated September 2014, included the following information: -The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order; -Check blood glucose per physician order or facility protocol; -Remove insulin vial/pen from storage point; -Check and re-check that the type of insulin on the vial/pen matches the type of insulin ordered; -Check the order for the amount of insulin; -Disinfect the top of the vial/pen with an alcohol…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2019-05-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure staff was prepared and stored food under sanitary conditions when staff did not keep potentially hazardous food at the proper temperature; staff failed date open food containers; staff failed to ensure the dish machine worked properly; staff failed to follow proper hand hygiene while serving food; and failed to wear hair restraints. The facility census was 96. 1. Record review of the facility's (undated) policy titled, cold holding, showed the following information: -Foods that require cold holding must remain at or below 41 degrees Fahrenheit (F); -Store the food in a refrigerated unit or refrigerated serving unit; -Do not let food stand at room temperatures because bacteria will grow; -Harmful microorganisms can grow on foods and cause illnesses when between 41 degrees F and 135 degrees F; -When using ice to keep cold foods cold, the ice should come up to the level of the food in the container; -Check foods often with a clean and sanitized metal stem thermometer to make sure cold foods stay below 41…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-05-22 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than five percent (5%) when staff made three errors out of 28 opportunities, resulting in an error rate of 10.71%, affecting three residents (Resident #22, #54, and #80). The facility census was 96. Record review of the Novolog and Humalog (rapid-acting insulins) manufacturer's inserts showed the following information: -Novolog and Humalog start acting fast; -A meal should be eaten within five to ten minutes of taking a dose of Novolog or Humalog; -Dosage adjustments may be needed in regards to timing of food intake. Record review of Medscape website (medical reference website for healthcare professionals) showed the following information: -Rapid acting insulins can cause hypoglycemia (low blood glucose). This may occur when enough calories are not consumed after taking the insulin within the time frame; -Older adults may be more sensitive to the side effects of low blood…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$16,335 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $16,335 — penalty dated 2026-05-04
  • Medicare payment denial — starting 2026-06-13 for 5 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
BRODERSEN, JENNIFERIndividualMANAGING CONTROL - GOVERNING BODYsince 02/01/2022
DIMOS, ROLANDIndividualMANAGING CONTROL - GOVERNING BODYsince 11/01/2024
MUNDIS, GREGORYIndividualMANAGING CONTROL - GOVERNING BODYsince 08/17/2024
WIEBE, CHRISTYIndividualMANAGING CONTROL - GOVERNING BODYsince 02/01/2022
MILLER, BRIANIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/24/2025
REINOLD, JEFFREYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 05/08/2023
MARANATHA VILLAGE INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/08/2008
FORVIS MAZARS LLPOrganizationADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.4M
Net patient revenuemost recent cost report
-27.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 44%Medicare 5%Other / private 52%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$327per resident / day
operating cost
$9,937per month
≈ monthly operating cost
$257per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MO

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Missouri Medicaid page.

Typical monthly cost in Missouri
$6,741/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,400/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 265475. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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