Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maranatha Village, Inc during CMS and state inspections, most recent first.
A resident with multiple chronic conditions experienced a fall and later developed low oxygen saturation, but staff failed to document timely assessments, monitor the resident adequately, and notify the physician as required by facility policy. Despite observing hypoxia symptoms and applying oxygen without an order, staff did not consistently record interventions or communicate the resident's declining condition to the physician, resulting in delayed medical intervention.
A staff member accepted multiple checks totaling about $7,000 from a resident who required substantial assistance with daily activities and was cognitively intact. The staff member discussed personal financial hardships with the resident, who then signed checks written out by the staff member. Facility policy prohibits staff from accepting money or gifts from residents, and interviews with staff confirmed this expectation. The issue was discovered by the resident's family and reported to the facility, leading to an internal investigation and police involvement.
A facility failed to document the specific needs it could not meet for a resident who was issued a discharge notice. The resident, with a history of COPD, CHF, anxiety disorder, and chronic kidney disease, exhibited delusions and rejected care multiple times a week. The facility did not document attempts to meet the resident's needs or the services available at the receiving facility. Interviews revealed the resident felt targeted for eviction, lacked 24-hour physician coverage, and had fired the medical director, contributing to the deficiency.
A resident with a history of flaccid neuropathic bladder experienced undignified treatment during a Foley catheter replacement by an LPN. The LPN made inappropriate sexual comments and failed to use lubricant initially, causing discomfort. Witnesses, including CNAs, reported the incident, which violated the facility's policies on resident dignity and respect.
The facility failed to maintain food safety and hygiene standards, including staff not wearing hairnets, improper storage of the ice scoop, and inadequate handwashing during meal service. These actions led to potential food contamination.
The facility failed to maintain their infection prevention program for Legionella by not following their water management program, neglecting preventative steps, and failing to educate staff. The Maintenance Director incorrectly believed Legionella could not grow in the pipes due to city water use, and the Director of Nursing confirmed lapses in monitoring and recording water temperatures. The Infection Preventionist was not involved in the water maintenance program as previously instructed by the Administrator.
The facility failed to provide required Bed Hold Notifications to residents and/or their responsible parties during hospital transfers for three residents. Interviews with staff revealed a lack of awareness regarding this requirement.
The facility failed to update comprehensive care plans for several residents, omitting critical information such as the use of oxygen and anticoagulant medication. These deficiencies were confirmed through medical records, observations, and staff interviews.
The facility failed to respect a resident's preference for nighttime care, causing distress and fear, and did not protect another resident's health information from public viewing, violating HIPAA regulations.
The facility failed to provide respiratory care per standards of practice when staff administered oxygen to two residents without physician orders. Both residents were observed receiving oxygen at two LPM without current orders, and staff confirmed the lack of proper authorization.
The facility failed to accommodate a diabetic resident's dietary preferences, providing high-carb meals and desserts despite clear instructions to avoid such items. Interviews revealed that dietary staff did not follow the resident's dietary card, leading to inappropriate meal service.
The facility failed to provide the pneumococcal vaccine as ordered for two residents. The vaccines were found in the medication room, and the RN confirmed that the IP was supposed to administer them but was unaware of their presence. Both the IP and DON stated that the expectation was for the vaccines to be administered as ordered.
Failure to Document and Notify Physician After Fall and Low Oxygen Saturation
Penalty
Summary
Staff failed to provide care according to standards of practice for a resident who experienced a fall and subsequently developed low blood oxygen levels. After the fall, the resident was found with injuries including skin tears and a hematoma on the forehead. Although a head-to-toe assessment and neuro checks were initiated, there was a lack of thorough and timely documentation regarding follow-up monitoring and the resident's condition in the days following the incident. The facility's policy required prompt notification of the physician and documentation of changes in condition, but these steps were not consistently followed. The resident, who had a history of pulmonary hypertension, chronic respiratory failure, heart failure, cerebral infarction, and sleep apnea, exhibited significantly low oxygen saturation readings, including a documented level of 72%. Despite facility protocols and physician orders requiring staff to notify the physician if oxygen saturation fell below 90%, there was no documentation that the physician was notified at the time of these low readings. Staff applied oxygen without a physician's order and did not consistently document assessments, interventions, or physician notifications related to the resident's declining condition. Multiple staff interviews revealed confusion about the facility's protocols for oxygen administration and physician notification. Staff reported difficulty obtaining accurate oxygen saturation readings and observed signs of hypoxia, such as bluish fingertips and confusion, but failed to document these findings or notify the physician in a timely manner. The lack of timely and complete documentation, monitoring, and physician notification contributed to a delay in appropriate medical intervention for the resident, who was eventually sent to the hospital after further deterioration.
Staff Member Accepted Multiple Checks from Resident, Violating Facility Policy on Misappropriation
Penalty
Summary
A facility staff member, a Certified Nurse Aide (CNA), received multiple checks totaling approximately $7,000 from a resident after discussing personal financial hardships with the resident. The resident, who was cognitively intact but required substantial assistance with daily activities due to multiple sclerosis, insomnia, and depression, reported that the CNA would write out the checks and the resident would sign them. The checks were written over several months, and the CNA was working at the facility on the days most of the checks were issued. The facility's policy strictly prohibits exploitation, theft, and misappropriation of resident property, including the acceptance of money or gifts from residents by staff. Interviews with various staff members, including RNs, CNAs, and the DON, confirmed that it is not appropriate for staff to ask for or accept money from residents, and that such actions constitute misappropriation of resident funds. The DON and Administrator both stated that staff are expected to report any such incidents to the appropriate supervisory personnel. The incident came to light when the resident's family discovered the checks and reported the matter to the facility, prompting an internal investigation and a police report. The facility's investigation confirmed that the CNA had received the checks from the resident, and that this was in violation of facility policy, regardless of the resident's stated intent to give the money as gifts.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure proper documentation for the discharge of a resident, identified as Resident #1, who was issued a facility-initiated discharge notice. The resident's medical record lacked documentation detailing the specific needs the facility could not meet, the attempts made by the facility to meet those needs, and the services available at the receiving facility to address those needs. Additionally, there was no documentation from the resident's physician regarding the basis for the discharge, which is required when a discharge is due to the resident's welfare and unmet needs. Resident #1 had a history of chronic obstructive pulmonary disease, congestive heart failure, anxiety disorder, and chronic kidney disease. The resident was cognitively intact but exhibited delusions and verbal behaviors directed at others multiple times a week. The resident also rejected evaluation and care, including medications and assistance with activities of daily living, several times a week. Despite these challenges, the facility did not document any care plan addressing the resident's noncompliance with medical care or orders. Interviews with the resident and facility staff revealed that the resident felt the facility was trying to evict them and had received multiple eviction letters. The resident's physician was not available 24 hours a day, and the resident had fired the medical director, leading to a lack of after-hours physician coverage. The facility's administrator and staff had discussed the need for 24-hour physician coverage with the resident, but no solution was found. The facility's failure to document these issues and the lack of a physician's input on the discharge decision contributed to the deficiency.
Inappropriate Conduct by LPN During Catheter Procedure
Penalty
Summary
The facility failed to ensure that staff treated all residents with dignity and respect, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who made inappropriate and degrading comments during a medical procedure. The incident occurred during the replacement of an indwelling Foley catheter for a resident with a history of flaccid neuropathic bladder and other medical conditions. The resident, who had intact cognition and functional impairments, was subjected to rude remarks by the LPN, who referenced sexual activity in a derogatory manner. The inappropriate behavior was witnessed by Certified Nursing Assistants (CNAs) who provided written statements detailing the LPN's conduct. The LPN reportedly did not use lubricant initially during the catheter insertion, causing discomfort to the resident, who exhibited signs of anxiety. The LPN's comments included references to the resident's sexual history and threats about the resident's leg positioning, which were deemed disrespectful and undignified. Interviews with facility staff, including the Director of Nursing (DON) and other CNAs, confirmed the inappropriate nature of the LPN's comments and actions. The facility's policies on resident rights and dignity, which emphasize respectful treatment and communication, were not adhered to in this instance, leading to a deficiency in maintaining the resident's right to a dignified existence.
Failure to Maintain Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to protect food from possible contamination in accordance with professional standards of practice. Observations revealed that staff did not consistently wear hairnets in the kitchen, which is a requirement to prevent hair from contaminating food. Specifically, a CNA was seen scooping ice without a hairnet, and the Maintenance Director repeatedly entered the kitchen without a hairnet, even after being instructed to wear one. Additionally, the ice scoop was improperly stored inside the ice container, potentially contaminating the ice. This was observed when a CNA and a CMT both placed the scoop back into the ice after use, despite being instructed otherwise by the Dietary Manager. Further observations during meal service showed improper hand hygiene practices. A Dietary Aide handled food and kitchen equipment without washing hands between tasks, which included placing a can of soup into bowls, retrieving a divider that fell into noodles, and serving the noodles to residents. These actions were performed without proper handwashing, potentially contaminating the food served to residents. The Dietary Manager confirmed that staff had been trained on these procedures but failed to follow them during the observed incidents.
Failure to Maintain Infection Prevention Program for Legionella
Penalty
Summary
The facility failed to maintain their infection prevention program to reduce the likelihood of Legionella in the water. The facility did not follow their water management program by neglecting to complete the preventative steps outlined and failing to ensure staff were educated regarding the water management program. The facility's policy required specific measures to control the introduction and spread of Legionella, monitoring control limits, and documentation of the program. However, the facility's documentation showed lapses in inspections and monitoring, with the last recorded eye wash inspection on 12/26/23 and the last recorded water temperature check on 03/18/24. The Maintenance Director (MD) incorrectly believed that Legionella could not grow in the pipes due to the facility using city water and was unable to report any control measures in place. The Director of Nursing (DON) and Infection Preventionist (IP) also demonstrated a lack of involvement and awareness regarding the water management program. Interviews revealed that the DON was aware that water should not sit still for more than two to three days and that unoccupied resident rooms should have their water flushed every two to three days. However, the DON confirmed that weekly water temperatures had not been monitored and recorded since 12/28/23, and the last meeting to review the Water Management Program was held on 06/22/21. The IP stated that she was previously told by the Administrator that the MD would handle the water maintenance program, leading to her lack of involvement. The facility census was 85 at the time of the survey, indicating a significant oversight in maintaining a critical aspect of infection prevention and control.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide the required Bed Hold Notification to residents and/or their responsible parties (RP) during hospital transfers for three residents. Resident #30, who was severely cognitively impaired, was transferred to the hospital and returned without any documentation of Bed Hold Notification. Similarly, Resident #50, who was cognitively intact, was discharged to the hospital and returned without receiving the Bed Hold Notification. Resident #50 confirmed during an interview that they did not receive any bed hold information and assumed everything would remain the same upon their return. Resident #67, also severely cognitively impaired, was transferred to the hospital and returned without any Bed Hold Notification documentation. The resident's family member confirmed they were notified of the transfer via phone but did not receive any written notification or Bed Hold Notification. Interviews with facility staff, including the Director of Resident Services (DRS), Director of Social Services (DSS), and Director of Nursing (DON), revealed a lack of awareness regarding the requirement to provide Bed Hold Notifications. The DRS and DSS both stated that they notified the RP by phone and sent an Emergency Transfer Notice but were unaware of the need to send Bed Hold Notices. The DON acknowledged that the Bed Hold Policy was included in the Admission Agreement Packet but was not aware of the need to provide a Bed Hold Notification at the time of hospital discharge.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to maintain and update comprehensive care plans for several residents, leading to deficiencies in care. Specifically, the care plans for four residents did not include the use of oxygen, despite medical records and observations indicating that these residents required oxygen therapy. For instance, one resident with acute and chronic respiratory failure and heart disease had an order for oxygen, but this was not reflected in their care plan. Similarly, another resident with heart disease and heart failure had an order for oxygen, which was also not included in their care plan. These omissions were confirmed by the Minimum Data Set Coordinator (MDSC) during interviews. Additionally, the care plan for a resident with chronic obstructive pulmonary disease (COPD) and heart disease did not include the use of oxygen, even though their medical records and observations showed they were receiving oxygen therapy. Another resident with a pulmonary embolism and COPD had an order for continuous oxygen, but this was not documented in their care plan. These discrepancies were also confirmed by the MDSC during interviews. Furthermore, the facility failed to care plan the use of anticoagulant medication for a resident with a prosthetic heart valve who was prescribed warfarin. The resident's care plan did not include any mention of the anticoagulant, despite the resident's medical records and personal confirmation of taking the medication. This oversight was acknowledged by both the MDSC and the Director of Nursing (DON) during interviews, indicating a failure to adhere to the facility's policy on comprehensive, person-centered care plans.
Failure to Protect Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to protect the dignity of Resident #50 by not respecting their preference for nighttime care. Despite the resident's cognitive intactness and clear communication of their discomfort with CNA #3's method of care, the CNA continued to handle the resident in a manner that made them feel unsafe and disrespected. The resident expressed that CNA #3 would roll them too close to the edge of the bed, causing fear of falling, and did not allow the resident to assist in their own care. This issue was corroborated by the resident's family member, who noted the resident's distress after being cared for by CNA #3. The facility administration and DON were unaware of the issue until it was brought to their attention during the survey, and CNA #3 admitted to not altering their care approach despite the resident's expressed concerns. Additionally, the facility failed to protect the health information of Resident #39 from public viewing. The resident, who was severely cognitively impaired and on hospice care, had a sign on the outside of their door indicating a fluid restriction. This sign was visible to other residents, staff, and visitors, which is a violation of HIPAA regulations. The resident was unaware of the sign's meaning, and the unit charge nurse and MDS Coordinator acknowledged that the sign should not have been placed on the door. This oversight exposed the resident's private health information to the public, compromising their confidentiality and dignity.
Failure to Obtain Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care per standards of practice when staff administered oxygen to two residents without physician orders. Resident #37, who was admitted with diagnoses including pleural effusion, unspecified fibrillation, heart disease, and hypertension, was observed on multiple occasions receiving oxygen via nasal cannula at two liters per minute (LPM) without a corresponding physician's order. The resident's nurse's progress notes documented the use of oxygen, but no orders were found in the electronic medical record (EMR) to support this treatment. The resident was cognitively intact and had a quarterly Minimum Data Set (MDS) assessment that did not include oxygen usage, further indicating the lack of proper authorization for the treatment provided. Similarly, Resident #9, who had diagnoses of acute and chronic respiratory failure with hypoxia and heart disease, was also receiving oxygen at two LPM without a current physician's order. The resident's care plan and significant change MDS did not include the use of oxygen, and the last documented physician's order for oxygen had been discontinued months prior. Despite this, the resident was observed receiving oxygen on multiple occasions, and interviews with staff confirmed the lack of a current order. The Director of Nursing (DON) and other staff members acknowledged that oxygen was being administered without proper authorization, which is against the facility's policy and federal guidelines.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's known dietary preferences, specifically for a resident with diabetes. The resident's admission record and dietary notes indicated a regular diet with no breads or desserts, and the resident was noted to be cognitively intact. Despite this, the resident received meals that included high-carb items such as breaded fish filet, hush puppies, and desserts, which were not suitable for a diabetic diet. The resident expressed dissatisfaction with the meals, noting that they were too sweet and did not meet their dietary requests, such as meat loaf, side salad, and tomato juice. Interviews with the Dietary Manager and Director of Nursing revealed that the dietary staff failed to follow the resident's dietary card, which clearly stated no breads or desserts. The Dietary Manager admitted that the dietary aide responsible for preparing the trays did not read the card properly. The Director of Nursing confirmed that the expectation was for staff to offer menu items and alternatives as per the resident's choice, which was not adhered to in this case. This led to the resident receiving inappropriate meals that did not align with their dietary needs and preferences.
Failure to Administer Pneumococcal Vaccine as Ordered
Penalty
Summary
The facility failed to provide the pneumococcal vaccine as ordered for two residents out of the seven reviewed for immunization. For Resident #43, the PCV 20 vaccine was ordered and scheduled to be administered on either 11/21/23 or 11/22/23. However, the vaccine was not administered, and there was no documentation explaining the failure. The vaccine was found in the medication room with a fill date of 11/08/23, and the RN confirmed that the Infection Preventionist (IP) was supposed to administer it but was unaware of its presence. Similarly, for Resident #75, the PCV 20 vaccine was ordered to be administered on either 03/11/24 or 03/12/24. The vaccine was not administered, and the only documentation noted that the resident was sleeping. The vaccine was found in the medication room with a fill date of 03/01/24, and again, the RN confirmed that the IP was supposed to administer it but was unaware of its presence. During interviews, the IP stated that the expectation was for the residents to receive the vaccine as ordered. The Director of Nursing (DON) also confirmed that the expectation was for the nurse on duty to administer the vaccine upon its arrival. The facility's policy on the pneumonia vaccine, revised in March 2022, did not address the procedure for who should administer the vaccine when it arrived at the facility, contributing to the oversight and failure to administer the vaccines as ordered.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Care & Rehab Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Wilson's Creek Nursing & Rehab | 4.5 mi | ★★★★★ | 4 | 0 |
| Brookhaven Nursing & Rehab | 4.5 mi | ★★★★★ | 4 | 0 |
| Manor At Elfindale, The | 4.8 mi | ★★★★★ | 10 | 0 |
| Springfield Skilled Care Center | 5.4 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.