Inspection Reports for
Maranatha Village, Inc

The facility failed to test and maintain the complete fire alarm system and failed to have inspections and written certifications of the approved sprinkler system completed by a qualified service representative. Both deficiencies affected all twenty residents present at the time of inspection.

The investigation was complaint-related concerning a facility-initiated discharge of Resident #1. The resident was discharged due to refusal to meet physician availability requirements and refusal of care. The complaint was substantiated by findings.

The facility failed to ensure proper documentation and communication regarding the transfer and discharge of a resident, including lack of physician documentation and failure to meet transfer criteria. The resident was discharged due to noncompliance with physician availability and refusal of care.

The complaint was substantiated based on interviews with staff including the Director of Nursing, Certified Nursing Assistants, and review of resident records and statements. The Licensed Practical Nurse was found to have made inappropriate sexual comments and behaved rudely during catheter insertion.

The facility failed to ensure staff treated residents with dignity and respect, as evidenced by inappropriate and degrading comments made by a Licensed Practical Nurse during catheter care for one resident. Multiple staff interviews and resident records confirmed the violation.

The facility failed to ensure the fire alarm system was free of faults and failed to maintain the building smoke separation by the required one-hour fire-rated smoke partitions. Both deficiencies affected all twenty-three residents present during the inspection.

The facility failed to develop and implement written policies ensuring complete screening of all staff members, including criminal background checks for two employees. The facility also failed to maintain a surety bond in the required amount to protect resident funds and lacked policies related to surety bonds and resident trust funds.

The facility was found to be in substantial compliance with emergency preparedness requirements but did not meet several provisions of the 2012 Life Safety Code, including sprinkler system installation, corridor doors, smoke barriers, and gas equipment storage. Deficiencies had the potential to affect all residents.

The facility failed to complete monthly reviews for four sampled residents for multiple months. Staff did not document monthly reviews for October, November, and December 2023 for Residents #1, #2, and #4, and for October and November 2023 for Resident #3. The Director of Residential Services acknowledged oversight in checking the monthly review list for three months.

Complaints #MO00226524, #MO00226413, #MO00226438, and #MO00226445 were investigated. The complaints involved resident rights violations, failure to notify physicians of changes, quality of care issues including pressure ulcer prevention and treatment, and incomplete resident records.

The facility was found noncompliant with federal regulations related to resident self-determination, notification of changes, quality of care including pressure ulcer prevention and treatment, and resident records. Specific incidents involved failure to honor a resident's right to leave the facility and call an ambulance, failure to notify physicians of changes in condition, and inadequate skin assessments and documentation.

The facility failed to ensure tuberculosis screening tests were completed for sampled residents and did not review advance directives annually for some residents. The facility census was 27 at the time of inspection.

The complaint investigation substantiated that Resident #1 was subjected to verbal abuse by Resident #2. The facility failed to report these allegations timely and did not provide adequate protective oversight or psychosocial services. The facility census was 102.

The facility failed to protect Resident #1 from verbal abuse by Resident #2, resulting in anxiety and distress. The facility also failed to report multiple allegations of resident-to-resident verbal abuse within the required timeframes.

The complaint investigation substantiated multiple deficiencies including failure to provide required Medicaid/Medicare notices, misappropriation of medications, failure to conduct timely background checks, failure to report alleged violations timely, and significant medication errors.

The facility failed to provide required Medicaid/Medicare notices to residents, protect residents from misappropriation of medications, conduct timely background checks, and ensure residents were free from significant medication errors. Multiple deficiencies were cited related to abuse/neglect policies, medication administration, and reporting requirements.

The facility failed to maintain magnetically locked emergency exits that release upon fire alarm activation, had deficiencies in smoke barrier walls and doors, and failed to properly store oxygen canisters separated from combustibles. These deficiencies had the potential to affect all residents, staff, and visitors in the event of a fire or emergency.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.

This complaint investigation found no deficiencies and the facility was compliant with infection control requirements related to COVID-19.

The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.

The facility was found to have medication errors exceeding the allowed 5 percent rate and multiple food safety violations including improper food temperatures, inadequate food labeling, and poor hygiene practices among dietary staff. Plans of correction were submitted addressing these deficiencies.

The facility failed to provide procedures for the use of volunteers in emergencies and had unsealed penetrations in the ceiling compromising fire safety. Additionally, a portable space heater was found in use, violating heating system regulations.

The facility failed to install self-closing devices on hazardous area doors, maintain the sprinkler system according to NFPA standards, use only approved fire-resistant wastebaskets, and ensure heating units met fire safety requirements. These deficiencies potentially affected all 22 residents present during the inspection.

The complaint investigation was substantiated. The facility failed to report alleged abuse within the required timeframe and failed to notify the Ombudsman of resident transfers or discharges as required.

The facility failed to report an alleged staff to resident abuse within the required timeframe. The investigation revealed a resident was hit with a pillow by a Certified Nursing Assistant, and the facility did not notify the state licensing agency within two hours as required. Additionally, the facility failed to notify the Ombudsman in writing of transfers or discharges for two residents.

The facility failed to meet several Life Safety Code requirements including delayed egress door signage, exit door locking mechanisms, smoke detection in emergency corridors, sprinkler system supervisory signals, fire door inspections, and call system requirements. Deficiencies had the potential to affect all residents, staff, and visitors.

The investigation was triggered by a complaint related to a resident fall and subsequent low oxygen saturation levels. The complaint was substantiated with findings that staff failed to notify the physician timely and did not document monitoring or interventions adequately.

The facility failed to document timely and complete assessments and monitoring, and failed to notify the physician promptly after a resident fall and when the resident exhibited low blood oxygen levels. Staff did not have an order for oxygen usage, and oxygen saturation levels were critically low without proper physician notification or documentation.

The complaint investigation was substantiated based on family reports of multiple checks totaling around $7,000 made out to CNA A over a period of time. The facility's investigation and police report confirmed the incident. CNA A was employed from 03/04/24 to 12/20/24. The resident confirmed giving money to CNA A as gifts after hearing about the aide's hardships.

The facility failed to protect residents from misappropriation of property when CNA A received approximately $7,000 from Resident #1 through multiple checks. The resident was cognitively intact but dependent on staff for care. Facility policy prohibits exploitation and misappropriation of resident property. Interviews confirmed staff acknowledged that accepting money from residents is inappropriate and constitutes misappropriation.

The complaint investigation found that the facility did not have proper documentation by the resident's physician regarding unmet needs, attempts to meet those needs, and the accepting facility's capabilities. The resident was discharged due to noncompliance, refusal of care, and lack of 24-hour physician coverage. The resident planned to appeal the discharge.

The facility failed to ensure documentation was present in the medical record to support the discharge, including lack of physician documentation on unmet resident needs, attempts to meet those needs, and services available at the receiving facility. Interviews confirmed the resident was discharged due to noncompliance and lack of 24-hour physician coverage, but documentation was incomplete.

The complaint investigation found that Licensed Practical Nurse B made inappropriate sexual comments and behaved rudely during a catheter insertion procedure for Resident #1. The complaint was substantiated based on interviews and written statements from multiple staff members and the Director of Nursing.

The facility failed to ensure staff treated residents with dignity when a Licensed Practical Nurse made rude and degrading comments to a resident during catheter insertion. Multiple staff statements and interviews confirmed the inappropriate behavior and comments, which were deemed very rude and disrespectful.

The facility was found deficient in multiple areas including failure to respect resident dignity, failure to provide bed hold notifications, incomplete care plans especially regarding oxygen and anticoagulant use, oxygen administration without physician orders, failure to accommodate resident dietary preferences, improper food handling and hygiene practices, inadequate infection prevention program particularly related to water management, and failure to administer pneumococcal vaccines as ordered.

Complaint #MO00226524 and related complaints #MO00226413, #MO00226438, and #MO00226445 regarding resident rights violations, failure to notify physician, and inadequate skin assessments and wound care.

The facility failed to allow a resident to leave to await an ambulance, failed to notify the physician of the resident's change in condition, and failed to complete proper skin assessments and wound care for two residents. Documentation of assessments and vital signs was incomplete.

The complaint investigation involved allegations of failure to provide Medicare notices, medication misappropriation, incomplete background checks, delayed abuse reporting, inadequate investigation of medication misappropriation, medication errors, and expired medications found in storage.

The facility failed to provide required Medicare notices to residents, protect residents from medication misappropriation by staff, complete timely criminal background checks for employees, report alleged abuse within required timeframes, properly investigate medication misappropriation allegations, and ensure correct insulin administration. Expired medications and supplies were also found in storage.

The facility failed to maintain medication error rates below 5%, with a 10.71% error rate in insulin administration affecting three residents. Additionally, multiple food safety violations were found, including improper food temperature control, failure to date mark open food containers, inadequate hand hygiene and glove use by dietary staff, failure to wear hair restraints, and malfunctioning dishwashing equipment.