Cycle 1
Health 2024-04-19 · Fire 2024-04-19
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Springfield, MO
Maranatha Village, Inc
3-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
233 East Norton Road, Springfield, MO
(417) 833-0016
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-12-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,290
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.89
Baseline 21.25% · Performance 19.16% · Measure score 4.89 · Achievement 4.89 · Improvement 4.44
Healthcare-associated infections
0
Baseline 5.54% · Performance 9.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.52
Baseline 40.00% · Performance 45.22% · Measure score 4.52 · Achievement 4.52 · Improvement 0
Adjusted total nurse staffing
3.95
Baseline 4.04 hours · Performance 4.2 hours · Measure score 3.95 · Achievement 3.95 · Improvement 0.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.52% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 9.2% · Lower 95% interval 8.08% |
| Discharge to community | 62.06% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 126 · Observed rate 58.73% · Lower 95% interval 54.29% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 64.62% |
53.69%
10.9 pts better
|
Numerator 42 · Denominator 65 |
| Discharge mobility score | 64.62% |
50.94%
13.7 pts better
|
Numerator 42 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.95% |
7.12%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 14.46% · Lower 95% interval 6.59% |
| Staff COVID-19 vaccination coverage | 2.35% |
8.2%
5.8 pts worse
|
Numerator 4 · Denominator 170 |
| Staff flu vaccination coverage | 7.87% |
42%
34.1 pts worse
|
Numerator 14 · Denominator 178 |
| Discharge function score | 73.85% |
56.45%
17.4 pts better
|
Numerator 48 · Denominator 65 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 10.26% |
25.2%
14.9 pts worse
|
Numerator 4 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
84.8%
13.7 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.6% · Q4 98.9% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.4% |
90.9%
1.5 pts better
|
95.5%
3.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
4.1%
0.9 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 4.8% · Q4 4.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
14.7%
13.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.4% · Q3 1.3% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
5.5%
3.7 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 5.1% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
25.3%
8.5 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 18.8% · Q3 17.4% · Q4 13.9% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
25.0%
6.1 pts better
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.0% · Q3 15.3% · Q4 18.5% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.8% |
20.3%
6.5 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 6.3% · Q3 19.0% · Q4 10.5% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.5% |
19.8%
7.3 pts better
|
14.9%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.1% · Q3 15.2% · Q4 10.7% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
1.4%
0.5 pts better
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.3% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
2.6%
2.5 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.9% · Q3 3.7% · Q4 6.7% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
18.1%
9.5 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.3% · Q2 33.2% · Q3 21.0% · Q4 25.7% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.0%
2.3 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 4.6% · Q3 2.8% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.9% |
66.4%
21.5 pts worse
|
81.7%
36.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 53.3% · Q2 43.5% · Q3 41.4% · Q4 41.4% · 4Q avg 44.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
13.4%
2.2 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 10.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.2%
0.6 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.4% · Q3 1.3% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.0% |
63.5%
34.5 pts worse
|
79.7%
50.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
25.3%
10.3 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 12.5% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-17 · Fire 2021-06-17
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-22 · Fire 2019-05-22
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-02
F · Potential for more than minimal harm
2024-04-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-04-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Not marked corrected
E · Potential for more than minimal harm
2024-04-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-02
E · Potential for more than minimal harm
2021-06-17
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-23
F · Potential for more than minimal harm
2019-05-22
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-06-25
E · Potential for more than minimal harm
2019-05-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-06-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-04-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-05-08
D · Potential for more than minimal harm
2024-12-03
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-30
D · Potential for more than minimal harm
2024-08-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-04-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-02
F · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-04-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-04-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-04-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-04-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-04-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-06-02
D · Potential for more than minimal harm
2024-04-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-02
D · Potential for more than minimal harm
2023-11-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-11-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-18
E · Potential for more than minimal harm
2021-06-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-07-23
E · Potential for more than minimal harm
2021-06-17
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-07-23
D · Potential for more than minimal harm
2021-06-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-23
F · Potential for more than minimal harm
2019-05-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-21
E · Potential for more than minimal harm
2019-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-06-19
Penalties and ownership
What sits behind the stars
Ownership
Maranatha Village Inc
Operational/Managerial Control · Organization
Miller, Brian
Corporate Officer · Individual
Reinold, Jeffrey
Operational/Managerial Control · Individual
Reinold, Jeffrey
Corporate Officer · Individual
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#3
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