Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to be treated with respect and dignity and to retain and use
personal possessions.

Based on observations and interviews the facility failed to respect the dignity of one
resident (Resident #132) when staff did not assure resident’s sides and abdomen remained
covered when in public areas. The facility census was 170.
1. Review of resident #132’s Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 9/11/18, showed:
– Impaired decision making skills;
– Required assistance with transfers, locomotion in hallways, dressing and personal
hygiene.
The MDS did not show the resident was a current tobacco user.
Review of the resident’s care plan, revised 9/20/18, showed:
– Requires one to two person assist with activities of daily living, grooming and eating;
– Resident needs supervision with eating;
– Resident will be well groomed at all times.
Observation on 10/18/18 from 7:42 A.M., until 8:27 A.M., showed the resident sat in the
assist dining room eating breakfast. The resident wore a white thermal-like shirt and a
pair of gray sweat pants. At least four inches of the resident’s bare skin on the right
side and across the front of his/her abdomen was visible to all residents and staff in the
dining room. Multiple staff spoke to the resident but did not pull down the resident’s
shirt to cover his/her abdomen and right side. At 8:27 A.M., the charge nurse adjusted the
resident’s shirt, which still left about two inches of his/her right side visible, and
pushed the resident to the doorway of the dining room. An office staff pushed the resident
on out into the hallway and to his/her room.
Observation and interview on 10/19/18 at 1:20 P.M., showed the resident sat in a line of
residents in a hallway close to the entrance of the facility. The resident sat in his/her
wheelchair with a dark coat on over a white shirt. The front of the shirt did not reach
the resident’s pants. The coat was open in the front, four to five inches of bare skin was
visible across the resident’s abdomen and on the resident’s side. The resident said he/she
was waiting to go outside and smoke. Another resident pushed the resident’s wheelchair in
the line of residents.
During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said staff should
make sure the resident’s skin was not showing when the residents were in public areas.

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to share a room with spouse or roommate of choice and
receive written notice before a change is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed discuss moving
the resident to another hall and failed to find a suitable room for one of 34 sampled
residents, (Resident #35), who required a bathroom large enough for his/her wheelchair.
The facility census was 170.
1. Review of the facility’s resident’s rights policy, reaffirmed, (MONTH) 22, (YEAR),
showed, in part:
– A room transfer of a resident within the facility, requires consultation with the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
resident as far ahead of time as possible and shall not be permitted where this transfer
would result in any avoidable detriment to the resident’s physical, mental, or emotional
condition.
2. Review of Resident #35’s annual Minimum Data Set (MDS), dated , 7/29/18, showed:
– Cognitive skills intact;
– Independent with bed mobility, transfers, dressing and toilet use;
– Lower extremities impaired on both sides;
– Always continent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s social services notes, dated, 9/10/18, at 5:00 P.M., showed:
– E-mailed deputy Public Administrator (PA) in regards to planned room move for 9/11;
– Requested return call or e-mail if any concerns or questions;
– Did not document if the room change was discussed with the resident.
Review of the resident’s care plan, dated, 9/24/18, showed:
– The resident is up ad lib in wheelchair and is able to transfer him/herself;
– The resident is at risk for falls related to medication use and disease process;
– One staff to assist the resident with mobility and transfers as needed.
During an interview on 10/17/18, at 9:31 A.M., the resident said:
– He/she was on the 800 hall and the staff moved him/her to the 900 hall because the
younger residents were going to be on the 900 hall;
– There are younger people than the resident on the 800 hall;
– Staff did not discuss the room change with the resident, just told him/her they were
being moved;
– In the new room he/she had problems getting into the bathroom with his/her wheelchair,
there was not enough room;
– The resident talked to the Administrator about it but nothing had changed.
During an interview on 10/17/18, at 2:42 P.M., Licensed Practical Nurse (LPN) A said:
– The resident was moved to the 900 hall because they were trying to get the younger
residents on one hall together;
– He/she was not aware of any problems with the bathroom.
During an interview on 10/19/18, at 8:54 A.M., the resident said:
– It was hard for him/her to get into the bathroom with his/her wheelchair;
– He/she had to sit on the toilet sideways;
– His/her wheelchair did not fit into the bathroom very well;
– He/she had mentioned it to various staff but no one had talked to him/her about it;
– When he/she was on the 800 hall, he/she did not have any trouble getting in and out of
the bathroom with his/her wheelchair;
– He/she would like to move back on the 800 hall.
During an interview on 10/19/18, at 5:52 P.M., the Director of Nursing (DON) said:
– Room changes are discussed by the Administrator, Social Services, DON or Assistant
Director of Nursing (ADON);
– It should be documented that we discussed the room change with the guardian and the
resident;
– The room change should have been discussed with the resident.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
self-determination through support of resident choice.

Based on observations, interviews and record reviews, the facility failed to create an
environment respectful of the rights of the each resident to make choices about
significant aspects of their lives. The facility census was 170.
1. Review of the facility policy for Resident’s Rights dated 3/22/17 showed:
-The resident has a right to a dignified existence, self-determination, and communication
with and access to persons and services inside and outside of the facility. The facility
must protect and promote rights of each resident;
-The resident has the right to be free of interference, coercion, discrimination and
reprisal from the facility in exercising his or her rights;
2. During a group interview on 10/17/18 at 10:30 A.M. the residents on the Rothwell,
Rothwell Senior, Parkwood and Parkwood Senior secured behavioral health unit said:
-All resident said there is not enough food. They are told that if they want seconds there
would have to be a physicians order obtained before a second portion could be given. Meals
are served late on the Parkwood and Parkwood Senior unit.
-The Parkwood and Parkwood Senior unit does not get served what is on the menu, dietary
runs out of the food and they are served what the kitchen has left.
– If there is a doctor’s order for large portions, the large portions not being served;
-If a resident does not show up for a meal, do not get served any food.
– If a want to sleep in of a morning, no breakfast is served. The resident may get a bowl
of cereal.
-There are not any snacks three times a day.
Observation on 10/18/18 at 7:56 A.M. showed eight trays were left on cart for the
residents for Rothwell Senior unit who did not come to the dining room. A staff member
took the remaining eight trays to the Rothwell Senior unit and placed them on a counter.
During an interview on 10/18/18 at 9:00 A.M. Certified Nurse Aide (CNA) A said:
-The seven breakfast trays were for the residents who did not get up for breakfast on the
Rothwell Senior unit. He/she has thrown away the food. No resident wanted to get out of
bed and eat the breakfast.
During an interview on 10/18/18 at 9:15 A.M. Resident #47 said:
-He/she just got up;
-He/she did not have any breakfast;
-The staff will not go to the kitchen to get any breakfast foods for those who want to
sleep in;
-He/she may get a bowl of cereal or a graham cracker when the staff pass snacks at 10:00
A.M.;
-But the staff does not always pass snacks at 10:00 A.M., if they don’t you have to wait
until lunch.
During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was
the Rothwell and Rothwell Senior unit manager, said:
– Food trays should not be left in the snack room for residents who slept during meal
service. Staff were to get food from the kitchen for residents who wanted to eat when they
woke up.
– Staff does not tell residents that they are not allowed to fist bump or hug.
During an interview on 10/19/18 at 4:43 P.M. the Dietary Manager (DM) said in order for
staff to serve residents increased food portions an approval by registered dietician or
resident’s physician was required.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
During an interview on 10/19/18 at 5:30 P.M., The administrator said:
– Staff should not serve residents food that has been left out for an hour. If residents
did not come to retrieve their food tray, the trays were to be sent back. It was not okay
for staff to let food trays sit out.
– Certified Nurse Aides (CNA)’s encourage residents to keep their rooms picked up. If the
residents do not pick up after themselves, staff will do it.
3. Observation on 10/19/18 at 12:00 P.M., showed staff served residents pork chops covered
in gravy. Staff did not provide a knife utensil with the meal service. Several residents
attempted to cut the pork chop with their fork but were not able. Residents attempted to
use their fork to lift the pork chop to their mouth in order to eat it but were
unsuccessful. Residents then picked up the gravy covered pork chop and ate it by hand.
An interview on 10/19/18 at 5:30 P.M. showed:
– Licensed Practical Nurse (LPN) A, who was the Rothwell and Rothwell Senior unit manager,
said staff does not provide knives to unit residents for meal service. Knives were not
allowed on the unit.
– The administrator said knives were not sent with meal service unless actually needed.
Residents could let staff know if they want a knife. Providing knives for dining service
was a safety concern. Butter knives were a safety threat. If residents asked, staff could
get them something to cut their meat .

F 0575

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Post a list of names, addresses, and telephone numbers of all pertinent State agencies
and advocacy groups and a statement that the resident may file a complaint with the State
Survey Agency.

Based on observations and interviews, the facility failed to post all required
information. The facility census was 170.
1. Observations on the Homestead unit during the survey on 10/16, 10/17.10/18, and 10/19
showed:
– No contact information for the Ombudsman.
– The state elder abuse hot line number was posted on the wall behind the nurse’s station
at a height of about six feet.
During a group interview with the Homestead and Meadow brook units, on 10/17/18 at 10:05
A.M. the residents said:
– They did not know who the Ombudsman was or what they did.
– They did not have a sign on their units with contact information for the Ombudsman.
– They had not seen the contact information for the elder abuse hot line.
During an interview on 10/19/18 at 4:55 P.M. the Administrator said:
– The facility posted the numbers for the Ombudsman and the elder abuse hot line.
– Residents frequently tore the contact information down.
– Staff did not make rounds to see if the notices were visible.
2. Observation on 10/16/18, 10/17/18 and 10/18/18 on the Rothwell and Rothwell Senior wall
showed:
-No resident rights posted, no addresses or phone numbers for the Missouri Division of
Aging, Missouri Department of Social Services, Missouri Ombudsman Program, Missouri

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0575

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Protection and Advocacy or Medicaid Investigation Unit and the most recent survey results
could not be found.
During a Resident Council Meeting with the residents on the Rothwell, Rothwell Senior,
Parkwood Senior and Parkwood halls on 10/17/18 at 10:30 A.M. the resident’s said: –
-The residents are not aware of any resident rights, there is a survey results signed
posted, but do not know where the survey results are at or have access to them.
-There are no outside phone numbers available to them, they are unaware of the Ombudsman
phone number or how to contact the Ombudsman. They are unaware of who to contact regarding
their guardianship and how to restore their rights.
3. Observation on 10/16/18, at 12:25 P.M., on the 800 hall (Parkwood Village), showed:
– A laminated sign above the pay phone in the commons area;
– The sign was too high for a resident in a wheelchair to read and the phone numbers for
State and the Ombudsman were in fine print and difficult to read.
4. During an interview on 10/19/18 at 2:00 P.M. the Customer Service Representative said:
-The addresses and phone numbers of the required agencies were not available for the
Rothwell and the Rothwell Senior units;
-The facility is attempting to find a way to post the required addresses and phone numbers
in a way that the is visible to the residents, yet so that the resident’s cannot remove.

F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on observations, on interviews, and record reviews, the facility failed to provide
residents with reasonable access to a telephone and privacy for phone conversations. The
facility census was 170.
1. Observations on 10/16, 10/17, 10/18, and 10/19 showed a pay phone for resident use on
the Homestead unit and a cordless phone locked inside the kitchen.
During a group interview, on 10/17/18 at 10:05 A.M., with residents from the Homestead and
Meadowbrook units the residents said:
– They had to use a pay phone to make phone calls.
– They had to call collect to the number and either hope the person accepted the call or
call them back.
– Most of their friends and family had cell phones and cell phones would not accept a
collect call.
– They could call someone from the pay phone if they purchased a phone card.
– After they got someone on the phone, sometimes staff would provide them with a portable
phone.
– Usually they just had to talk on the pay phone.
– They would like to be able to make and receive phone calls in private.
– They cannot afford phone cards.
During an interview on 10/19/18 at 5:24 P.M. the Administrator said:
– Residents could call collect or use a phone card on the pay phone.
– The units all had a cordless phone that residents could receive phone calls.
– Residents needed to ask staff for the cordless phone.
2. Observation on 10/16/18, at 12:25 P.M., showed a pay phone in the commons area on the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
800 unit.
During an interview on 10/17/18, at 2:36 P.M., Resident #126 and Resident #9 said:
– There’s a white portable phone locked up in the snack room;
– You can not call out on the white portable phone;
– You have to use the pay phone to make calls;
– When your family calls back, you can use the white portable phone.
3. Observation on 10/16/18, 10/17/18, 10/18/18 and 10/19/18 showed a pay phone for
resident use on the Rothwell hall.
During a group interview on 10/17/18 at 10:30 A.M. with the residents on Rothwell,
Rothwell Senior, Parkwood, Parkwood Senior halls the residents said:
-The resident’s have to use a pay phone in the hall if they want to make a call and use a
calling card. If the resident does not have a calling card, then they have to make a
collect call. Not all cell phone will accept collect calls;
-The residents on the Rothwell Senior hall had to go to the Rothwell hall to use the pay
phone;
-The doors are locked between the two halls;
-They had to wait for a staff member to be available to take them to the Rothwell hall to
use the pay phone.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to assure staff indicated in
the resident’s medical record their wishes for CPR (Cardo [MEDICAL CONDITION]
Resuscitation) and documented the residents choice of code status in such a way to be
readily accessible to staff in the event of an emergency. This affected three residents
(Resident #64, #147 and #153) out of 34 sampled residents. The facility census was 170.
Review of the facility for Advance Directives dated [DATE] showed:
-It is the policy of this facility to follow the directions given by each resident with
regard to accepting or refusing medical or surgical treatment to the extent permitted by
law;
-At the time of admission as a resident of the facility, the resident will be provided
with written information concerning the resident’s rights under state law, both statutory
and case law, to make decisions concerning medical care, including the right to accept or
refuse medical or surgical treatment, and the right to formulate advance directives;
-There shall be documented in the resident’s medical record whether the resident has
executed any advance directives, and copies shall be made a permanent part of the
resident’s medical record;
-Advanced directive includes a living will, durable power of attorney for health care or
any other written document executed by the resident, signed, and dated that expresses the
individuals health care treatment decisions;
-The Administrator, Social Services Director, Consumer Service Consultant and all nursing
staff shall be educated about advance directives and this policy.
1. Review of Resident #64’s quarterly Minimum Data Set (MDS), a federally mandated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
assessment instrument completed by staff dated [DATE] showed:
-Alert and able to make decisions;
-Independent with Activities of Daily Living (ADL’s);
-[DIAGNOSES REDACTED].
Review of the medical record showed:
-The face sheet listed the responsible party on as the resident’s mother and father;
-Code Status – Full code
– Attachment U (a facility form indicating advanced directives) listed as Full Code.
-Physician order [REDACTED].
-physician progress notes [REDACTED].
2. Review of Resident #153’s MDS, dated [DATE], showed:
– Both short and long term memory problems;
– Required assistance with activities of daily living;
– [DIAGNOSES REDACTED].
Review of the medical record showed:
– The face sheet listed the responsible party as the resident’s daughter;
– Code Status – Full code;
– Attachment U (a facility form indicating advanced directives) listed as DNR (Do Not
Resuscitate) signed by the resident’s daughter;
– Physician order [REDACTED].
3. Review of Resident #147’s MDS, dated [DATE], showed:
– Both short and long term memory problems;
– Required assistance with activities of daily living;
– [DIAGNOSES REDACTED].
Review of the medical record showed:
-The face sheet listed the resident had been assigned a guardian;
-Code Status – Full code
– Attachment U (a facility form indicating advanced directives) listed as DNR;
-Physician order [REDACTED].
During an interview on [DATE] at 1:36 P.M., Licensed Practical Nurse (LPN) D said:
He/she floated and worked in all units of the facility;
– There were several places in the resident’s medical chart to find out the resident’s
code status. The first page of the record on the face sheet, on admission paper work and
on the physician’s orders [REDACTED].
During an interview on [DATE] at 9:30 A.M. the Director of Nursing (DON) said:
-She does not know why the physician documented the resident as a DNR;
-All documentation in the medical record should match the code status of the resident.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record reviews the facility failed to inform two residents
(Residents #48 and #103) when changes were made in his/her Medicare coverage prior to the
end of service date. The facility census was 170.
1. Review of Resident #103’s NMNC showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– The facility sent a certified letter to the resident’s Public Administrator (PA) on
6/6/18.
– The resident’s services ended on 6/7/18.
– No other documentation of attempting to contact the resident’s PA by phone or any other
means prior to the end of service;
– The resident’s Public Administrator signed the notice on 6/18/18.
Review of Resident #48’s NMNC showed:
– The facility sent a certified letter to the resident’s PA on 7/20/18.
– No other documentation of attempting to contact the resident’s PA by phone or any other
means prior to the deadline;
– The resident’s services ended on 7/23/18.
– The resident’s PA signed the notice on 8/1/18.
During an interview on 10/19/18 at 3:00 P.M the Social Services Director (SSD) said:
– He/she thought the NMNC needed to be sent only one day prior to the end of services.
– He/she sent the NMNC to a resident’s guardian but did not fax or call to ensure the form
was signed two days prior to the end of service.
During an interview on 10/19/18 at 3:00 P.M. the Administrator said:
– The SSD was responsible for sending out the NMNC notices to any resident with a PA.
– He/she thought that the SSD should notify the resident’s PA one day before the end of
services.
– He/she did not instruct the SSD to call the resident’s PA 48 hours prior to the end of
services,.
– He/she thought as long as the SSD mailed the NMNC one day prior to the end of services,
no further facility follow up was needed.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain resident use areas in
a clean homelike manner when resident rooms and common areas were not kept clean and
maintained. The facility census was 170.
1. Observations throughout all days of survey from 10/16/18 through 10/19/18 showed:
– Dead bugs in ceiling lights located in resident room restrooms for rooms 102, 105 and
304.
– Privacy curtains either not in the room for each resident in a shared room and/or not
secured in room [ROOM NUMBER],101, 102, 107, 201, 204 and 206.
– No light covers in resident rooms 111, 302, 311 and 315 restrooms
– Resident rooms including room [ROOM NUMBER], 303, 306, 308, 309, 311, 315, 316 had room
ceiling vents covered with dirt and dust and /or a loud sounding motor.
– Wall paint chipped and/or dented, spotted and damaged in rooms 303, 309, 408, 605, 701,
707 and 101.
– Floor tile up to 100 percent of the area either stained and/or dirty, marked, sticky,
dusty, streaked, wax build up and separation between tiles in rooms 303, 308, 311,400,
402, 406, 408, 409, 411, 500, 501, 502, 504, 507, 508, 509, 601, 603, 604, 605, 702, 707,
701, 704, 707, 202, 101, 103, 107, the 200 hall corridor and 400/500 hall dining room.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
– Ceiling tile stained in room [ROOM NUMBER].
– Panel wall trim off and/or floor trim off or loose trim in resident rooms and /or
restrooms for rooms 401,405,505 and 600.
– Resident room restrooms had either a strong odor of urine and/or sticky, pink substances
on walls for rooms 400, 401, 402, 408, 411 and 502.
– Room doors scuffed and/or dirty and damaged for rooms 405,409, 603 and 702.
– Shower room in 400 hall had a scuffed housekeeping closet.
– No baseboard or no baseboard paint and/or loose baseboards in rooms and/or restrooms
located in room [ROOM NUMBER], 506 and 603.
– Near an exit door on the 500 hall the baseboard and the exit door was dirty with trim
around windows chipped.
– The toilet paper holder was dirty in room [ROOM NUMBER].
– Strong soiled linen smell in room [ROOM NUMBER].
– Drawers with chips in room [ROOM NUMBER].
– Plywood covering the window in room [ROOM NUMBER].
– No Closet curtains or closet curtains coming off the rails in rooms [ROOM NUMBERS].
– Broken tile by the window in room [ROOM NUMBER].
– White wrapping peeling off the pipes by the west 100 hall exit door to the enclosed
court yard.
– The main dining room had a door to the courtyard that was dented and stained over 75
percent of the surface area with a dirty window. The room trash can lid had food
substances and particles on the lid handles and was touched numerous times by residents
and staff. The white cabinets in the room were missing knobs and were stained and dirty
with food substances. The interior of the white cabinets were dirty and contained a
partial container of pop, dead bugs, food particles and drink substances. The exterior of
vending machine was 50 percent speckled with gray and white substances. The 16 ceiling
light fixtures in the room contained dead bugs. The double doors near the vending machine
was dirty and stained over 25 percent of the door area. The ceiling paint in the corner of
the room was pealing off and stained over a 13 foot by 9 foot area.
– The unit refrigerators of the Rothwell and Rothwell Senior unit had a thick build-up of
ice.
During observation and interview on 10/17/18 at 1:48 P.M., the Assistant Director of
Nursing (ADON) said resident room [ROOM NUMBER] floor was so sticky it caused shoes to
stick to the floor. Certified Nurses Aides (CNA) K and CNA L also said the room floor was
sticky.
During an interview on 10/19/18 at 4:15 P.M., the Environmental Director (ED) said all
identified areas shown in environmental observations were areas of concern that needed to
be fixed. Floors were sticky, discolored and needed to be refinished. Some rooms had
strong urine odors that they were trying to address. Unit staff should clean the
refrigerators in their units. He was unaware if it was his responsibility or someone
else’s to assure light fixtures were kept clean. The trash can in the main dining room was
cleaned every other week. It was not acceptable for residents and staff to touch a dirty
trash can with food particles on it.
During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager said staff should keep
the lid on the dining room trash can clean. It was unsanitary for residents and staff to
touch a dirty trash can lid.
During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was
the Rothwell and Rothwell Senior unit manager, said staff should not let thick ice
build-up on the refrigerators. The unit night shift nurse was responsible for defrosting
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
the refrigerators.
During an interview on 10/19/18 at 5:30 P.M., the Administrator said:
– Certified Nurse Aides (CNA)’s encourage residents to keep their rooms picked up. If the
residents do not pick up after themselves, staff will do it.
– Residents’ spilt drinks and make messes in their rooms daily.
– Window blinds were provided in resident rooms for privacy.
– The build-up of dirt was down in the floor tile and would be addressed when the unit
remodel was complete.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to follow the recommended
guidelines when administering nasal spray and did not administer food with Vitamin D 3 for
one of 34 sampled residents, (Resident #32). Additionally, staff failed to clarify
specific times for medications scheduled every 12 hours; failed to monitor food allergies
[REDACTED]. Staff failed to date when opened oxygen tubing and oxygen humidifier and
failed to clean an oxygen concentrator filter which affected one resident (Resident #105).
The facility census was 170.
1. Review of the facility’s medication administration and monitoring policy, reaffirmed,
(MONTH) 6, (YEAR), showed, in part:
– The nurse or Certified Medication Technician (CMT) will check each medication to the
Medication Administration Record [REDACTED]
– It is imperative that all medications are given using he seven rights to medication
administration and that the professional caregiver ensures that medications are swallowed:
right resident, right medication, right dose, right route, right time, right documentation
and right dosage form;
– If time is specified, give medication as ordered on time (specified medications should
be scheduled to best reflect the physician’s orders [REDACTED].>- Medications that are
to be given with food, will be given within 30 minutes before or 30 minutes after the meal
consumption;
– If the medications must be given with food, and it is out of the 30 minute window, then
a small snack will be provided to the resident to prevent GI upset, according to their
diet.
Review of the website, www.[MEDICATION NAME].com.dosage and administration, showed:
– Blow your nose gently to clear nostrils;
– Put the tip of the spray nozzle into a nostril and tilt head forward while keeping
bottle upright.
2. Review of Resident #32’s consumption sheet, dated, October, (YEAR), showed:
– The staff documented the resident refused breakfast (MONTH) 1st through (MONTH) 16th;
– Staff did not document a percentage for breakfast on (MONTH) 17th.
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].M. to 11:00 A.M.;
– an order for [REDACTED]. to 11:00 A.M.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
Review of the resident’s MAR, dated, October, (YEAR), showed:
– [MEDICATION NAME] ([MEDICATION NAME]) nasal spray, 50 mcg., two sprays in each nostril
daily for allergies [REDACTED].M. to 11:00 A.M.;
– Vitamin D 3, 2000 units daily with food for nutritional deficiency, scheduled time 7:00
A.M. to 11:00 A.M.
Observation on [DATE], at 9:06 A.M., showed:
– CMT C placed the Vitamin D 3 in a plastic medication cup and added a heaping teaspoonful
of applesauce and administered to the resident;
– CMT C handed the resident the [MEDICATION NAME] ([MEDICATION NAME]) nasal spray and
instructed the resident to hold one side of his/her nose and spray in the open nostril and
repeat on the other side. The resident administered two sprays to each nostril;
– The resident did not blow his/her nose before administering the nasal spray and did not
lean forward during the administration of the nasal spray.
During an interview on [DATE], at 9:30 A.M., the resident said:
– He/she did not eat breakfast this morning;
– He/she did not eat breakfast because he/she had gastric bypass done and only ate lunch
and dinner.
During a telephone interview on [DATE], at 7:20 P.M., CMT C said:
– He/she should have offered the resident something to eat;
– He/she should have followed the guidelines for the nasal spray.
During an interview on [DATE], at 5:52 P.M., the Director of Nursing (DON) said:
– If the physician ordered to give medication with food, a teaspoonful or tablespoon of
applesauce would not be enough, it would need to be a substantial amount;
– The staff should follow the guidelines for the nasal spray.
3. Review of Resident #35’s POS, dated, (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR),
showed:
– an order for [REDACTED].M. to 11:00 A.M. and 6:00 P.M. to 10:00 P.M.;
Review of the resident’s MAR, dated, (MONTH) 1, (YEAR) to (MONTH) 31, (YEAR), showed:
– [MEDICATION NAME] 20 mg. twice daily, scheduled at 7:00 A.M. to 11:00 A.M. and 6:00 P.M.
to 10:00 P.M.
During an interview on [DATE], at 5:52 P.M., the DON said:
– The staff should get the pain medication times clarified or give at the time stated on
the MAR.
4. Review of Resident #80’s face sheet, showed:
– Re-admitted [DATE];
– allergies [REDACTED].
Review of the resident’s care plan, dated, [DATE], showed:
– The resident was on a regular diet and had food allergies [REDACTED].
– Ensure allergies [REDACTED].
Review of the resident’s POS, dated, (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), showed:
– The resident had an allergy to cinnamon.
Observation and interview on [DATE], at 2:00 P.M., showed:
– The resident said he/she was served apple pie which had cinnamon in it;
– The apple pie smelled like it had cinnamon in it.
During observation and interview on [DATE] at 1:59 P.M. Cook A showed a can of the apple
pie filling he/she used in the fruit cobbler he/she prepared for lunch. The can showed
ingredients included spices. Cook A was not aware of what spices were included in the
apple pie filling. A taste sample of the cobbler showed a taste of cinnamon.
During an interview on [DATE] at 6:03 A.M., Cook A said they checked with company who
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
provided the apple pie filling and were not able to find out what spices were in the
filling.
During an interview on [DATE] at 9:40 A.M., Cook A said they had no way to know what the
spices were in the apple pie filling served to the resident. He/she thought the spices
could include cinnamon. The kitchen staff did not check and should check for resident
allergy restrictions prior to meal service to assure residents dietary restrictions were
met.
During an interview on [DATE] at 12:03 P.M., Dietary Adie (DA) A said since [DATE], when
the resident was served apple cobbler, the resident’s dietary card went missing. The card
showed the resident was allergic to cinnamon and other food items but he/she cannot find
it.
During an interview on [DATE] at 4:43 P.M., the Dietary Manager (DM) said she would expect
spices in apple pie filling would include cinnamon. Staff should not serve residents foods
that were restricted from their diets.
During an interview on [DATE], at 5:52 P.M., the DON said:
– The CNA’s should check the resident’s dietary card before they serve any food;
– The resident’s allergies [REDACTED].
5. Review of the CPR-D-padz (used to shock a resident in case of [MEDICAL CONDITION])
showed staff should not open the pads until ready to use.
Observation on [DATE] at 2:26 P.M. of the emergency crash cart on the Meadowbrook Hall
showed:
– An opened package of CPR-D-padz.
During an interview on [DATE] at 2:26 P.M. the Business Office Manager said:
– He/she checked the facility crash carts on a daily basis.
– He/she was not aware that the CPR-D-padz should not be opened until ready for use.
6. Review of Resident #105’s care plan, dated [DATE], showed:
– The resident was at risk for altered respiratory status due to lung disease.
– Staff should administer oxygen to the resident as needed.
– Did not address the resident changing the liter flow on his/her oxygen concentrator.
Review of the resident’s significant change in condition Minimum Data Set (MDS), a
federally mandated assessment instrument completed by facility staff, dated [DATE],
showed:
– Moderate cognitive impairment;
– [DIAGNOSES REDACTED].
– The resident smoked tobacco;
– The resident denied shortness of breath;
– The resident received oxygen therapy.
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– Staff could administer breathing treatments to the resident as needed for shortness of
breath;
– Did not discuss oxygen therapy.
Observation on [DATE] at 11:28 A.M. of the resident in his/her room showed:
– The resident was using oxygen from tubing and a humidifier that were not labeled when
staff opened them.
– The resident moved his/her oxygen tubing from the humidifier directly to the flow meter
(bypassing the humidifier)
– The resident was adjusting his/her oxygen liter flow while taking to the surveyor.
– The resident’s oxygen concentrator filter was dusty.
Observation on [DATE] at 10:45 A.M. showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
– The resident’s oxygen tubing and humidifier not labeled when opened.
– The resident’s oxygen tubing on the floor.
During an interview on ,[DATE] /18 at 10:45 A.M. the Director of Nursing (DON) said:
– The resident’s oxygen tubing should not be on the floor.
– The resident’s oxygen tubing and humidifier should be labeled when opened and changed
weekly and as needed.
– Staff should clean the resident’s oxygen filter.
– Did not specify which staff should clean the oxygen filter.
During an interview on [DATE] at 8:15 A.M. Licensed Practical Nurse (LPN) B said:
– He/she was the resident’s unit manager.
– Staff must label oxygen tubing and humidifiers when opened.
– Staff must change resident’s oxygen tubing weekly and as needed.
– The night shift must clan oxygen concentrator filters as needed.
– Staff must ensure thee resident’s oxygen was attached to a humidifier.

F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Plan the resident’s discharge to meet the resident’s goals and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and interviews, the facility failed to develop a discharge plan
according to the resident’s wishes for two sampled residents (Resident #93 and Resident #
130) out of 39 sampled residents. The facility census was 170.
1. Review of Resident # 93’s MDS, dated [DATE], showed:
– Capable of making decisions;
– Needed only supervision/cueing with personal hygiene, eating and bathing;
– Independent in other activities of daily living;
– No mood disorders noted;
– No behaviors noted;
– [DIAGNOSES REDACTED].
– No discharge plan.
Review of the resident’s social service note, dated 8/9/18, showed:
– The resident able to communicate wants and needs effectively.
– The resident continues to request to move to independent living near his/her sisters
though the guardian has explained that moving back to the St. Louis area is not an option
at this time.
– Current plan is continued placement at the facility and for Social Services to meet with
the resident as needed or requested.
Review of the care plan last updated 9/18 showed:
– Discharge plans per guardian is for continued long term placement;
– Resident has expressed desire to move closer to family in to a residential care
facility. Guardian stated unable to move at this time.
-Goal: Maintain current physical and mental health;
-Approaches: interdisciplinary team to meet with resident and guardian via phone at
facility to discuss current placement; hospital evaluation and treatment as needed or
ordered. Undated handwritten note: Will follow guardian directives/wishes at this time.
Will communicate resident’s needs/desires to guardian as requested/needed.
Following a group meeting at 10/17/18 at 10:05 A.M., which the resident attended and again

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
on 10/19/18 at 4:30 P.M., the resident asked to speak to the surveyors present. The
resident stated:
– He/she had repeatedly requested to move closer to his/her sisters on the eastern side of
the state;
– His/her sisters were older than the resident and it was difficult for them to make the
long round trip to visit him/her, plus the trip was costly;
– He/she had requested to move to a residential care facility;
– He/she had caused no problems while at the facility, took his/her medications as
ordered, basically took care of him/herself and had no behaviors;
– He/she did not feel Social Services at the facility had helped him/her to be able to
move closer to his/her family;
– He/she asked for information of any agency or resource that could assist him/her;
– He/she did not feel the guardian or judge should say the reason he/she could not move
was because the guardian did not get paid enough for mileage to go see the resident closer
to the eastern side of the state;
– He/she felt the judge could appoint him/her a different guardian if he/she still needed
one;
– The resident went on to discuss finance, insurances and the job he/she held prior to
placement at a long term care facility.
During an interview on 10/19/18 at 12:22 P.M., the Social Service Director (SSD) and
Administrator said:
– During scheduled guardian meetings with the resident, the unit coordinator and herself
discussion of what the guardian has planned for the resident’s discharge is held;
– If what the guardian had planned was not in the best interest of the resident, she
tried to speak to the guardian;
– The guardian told her the judge that placed the resident with the guardian will only
place residents in certain geographical areas to cut down on travel costs;
– The guardian told her the resident could not move, it was too far away and would cost
too much for the guardian to where the resident wanted to move;
– She felt the resident could live in a lesser restrictive environment;
– She or the Administrator was unaware of any other resource to use that would help
advocate for the resident.
2. Review of Resident #130’s Preadmission Screening and Resident Review (PASRR)/MI (Mental
Illness) form (a federally mandatory screening process for individuates with serious
mental illness and/or mentally retarded/developmental disability related [DIAGNOSES
REDACTED].
-[DIAGNOSES REDACTED].
-History of psychiatric hospitalization s;
-Nursing facility short term stay and services recommended to adjust medication and allow
to stabilize;-
-Does not require secured placement;
-Short term recommendations: Nursing facility must initiate discharge planning to evaluate
appropriateness of move to less restrictive setting including referrals to community
services providers as applicable.
Review of the psychosocial history dated 12/5/17 showed:
-Services needed/suggested: therapy, dental, audiology, ophthalmology, podiatry, and
psychiatric;
-Legal guardianship in place;
-Anticipated length of stay: until desired level of independence is achieved;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-Goals and future desired outcomes: go to school, get a career and work full time.
Review of the care plan for discharge date d 12/26/17 showed:
-The Public Administrator plans for continued long term placement;
-Goal: Maintain current physical and mental health;
-Approaches: nursing and social services to meet with guardian via phone and at facility
to discuss current placement; hospital evaluation and treatment as needed or ordered.
Review of the care plan for the resident will not cause significant harm to self or others
dated 3/26/18 showed:
-9/30/18: resident reports ingested shampoo, unwitnessed; approaches to send to
psychiatric hospital for evaluation;
-Undated problem: the resident stated got upset because guardian retired and didn’t pass
on information to possibly go to Residential Care Facility (RCF) in the future; approach:
offer reassurance, notify guardian of questions or concerns, assist the resident as needed
and inform the resident that making false statements or attention seeking behaviors would
not him/her move to a less restrictive environment.
Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument
completed by staff dated 9/11/18 showed:
-Alert and oriented and able to make decisions;
-No mood or behavior concerns;
-Independent with ADL’s;
-[DIAGNOSES REDACTED].
-No discharge plan.
Review of the social services notes dated 9/13/18 at 9:48 A.M. completed by the Social
Services Director (SSD) showed:
-The resident has expressed a desire to return to a lesser restrictive environment however
his current guardian feels that his/her mental health needs to continue to stabilize
before he/she will consider moving him/her.
During an interview on at 10/18/18 06:34 AM the Resident stated that he/she was working on
a six month program to be discharged to a less restrictive area. His/her Public
Administrator (PA) was changed and now all discharge plans have been stopped. He/she would
like to be able to work toward discharge planning. No one has worked with him/her on any
discharge planning or goals.
During an interview on 10/16/18 04:24 P.M. the Social Services Director said:
-The resident was recently hospitalized for [REDACTED].
-He/she was aware that the resident wanted to go to a less restrictive environment;
-There is no current discharge plan in place nor has he/she talked with the resident about
possible discharge plans or goals;
-The guardian has not indicated that the resident could be discharged to an RCF;
-He/she has not discussed discharge planning with him/her.
During an interview on 10/19/18 at 4:00 P.M. the Administrator said:
-There are no current psychosocial therapy or discharge planning in place;
-He is unaware of any goals the resident had made with the prior or present guardian about
being discharged to a less restrictive environment.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide care and assistance to perform activities of daily living for any resident who
is unable.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
who were unable to carry out their own activities of daily living (ADLs) received the
necessary services to maintain good personal hygiene when staff did not remove facial hair
as needed for one of 34 sampled residents (Resident #154) and when they failed to provide
complete perineal cleansing for three dependent incontinent residents (Resident #37, # 147
and #153), The facility census was 170.
1. Review of the facility policy for Peri-Care, reaffirmed 4/6/17, showed:
– To ensure that the male and female genital area is kept clean and proper techniques are
used to prevent skin break down, infections or any other impairments that can be caused
from not using roper aseptic technique;
– Peri-care is very important in maintaining the residents’ comfort;
– More frequent care is required for residents who are incontinent;
– Always wash front to back to prevent spreading fecal matter from the anal area to the
vagina or urethra (opening to the bladder);
-Expose peri area, gently wash the inner legs, gently open all skin folds and cleanse
from front to back;
– Start with the innermost area and proceed cleansing outward.
2. Review of Resident #147’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/23/18, showed:
– Both short and long term memory loss;
– Required extensive assist with bed mobility, toilet use and personal hygiene;
– Frequently incontinent of urine and occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 10/8/18, showed
– Resident will be clean, dry and odor free;
– Provide peri-care after each episode of incontinence and as needed.
Observation on 10/16/18 at 4:07 P.M., showed the resident lay in bed on a wet incontinent
pad. Certified Nurse Aide (CNA) I and J provided peri care for the resident prior to
transferring the resident to his/her wheelchair. CNA I did the following:
Poured a bottle of No Rinse peri rinse into a basin of warm water and placed washcloths
in the basin;
– He/she used different washcloths with each wipe and cleaned once down each groin and
wiped twice down the center;
– He/she wiped the resident from the rectum to the coccyx and cleaned the right buttock
and between the resident’s inner thighs.
CNA I did not thoroughly manipulate and cleanse all the perineal folds and clean the left
buttock.
During an interview on 10/19/18 at 2:40 P.M., CNA I said:
– He/she should always wipe in a front to back direction;
– He/she should wipe down each groin and then clean the middle, wiping until clean;
– He/she should roll the resident to the side and clean one buttock and down the middle
front to back. Then roll the resident over and clean the other buttock.
3. Review of Resident #153’s MDS, dated [DATE] showed:
– Unable to make daily decisions;
– Required extensive assist with bed mobility, toilet use and personal hygiene;
– Frequently incontinent of urine and bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 10/4/18, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
– One to two staff will assist the resident with activities of daily living including
personal hygiene.
During an observation 10/18/18 at 5:54 A.M., showed the resident lay on an incontinent ad
soiled with urine. Urine soaked the incontinent pad up to the top edge of the pad that lay
half way up the resident’s back. CNAs F and G provided pericare for the resident. CNA G
did the following:
– Asked CNA F to retrieve a clean incontinent pad and proceeded to wipe one time down each
groin folding the wash cloth once between the wipes;
– Rolled the resident to his/her side and wiped once from the rectum to the coccyx, folded
the washcloth and wiped once on each buttock from front to back, folding the cloth between
each wipe;
– CNA G rolled a clean incontinent pad under the resident.
CNA G did not manipulate and wash all the perineal folds, between the inner thighs, hips
or up the resident’s back that lay on the soiled incontinent pad.
During an interview on 10/18/18 at 6:29 A.M., CNA D said:
– He/she should wipe own each groin area and then down the middle;
– After he/she dried the front side of the resident, he/she should clean the backside,
fold the washcloth between each buttock, fold the washcloth again and wipe up the middle
of the backside;
– He/she should have washed the resident’s hip that lay in urine and up the resident’s
back that lay on the wet incontinent pad.
4. Review of Resident #37’s care plan, dated, 4/30/18, showed:
– The resident required extensive assistance of two staff for activities of daily living
(ADL), grooming and hygiene tasks related to [MEDICAL CONDITION] (impaired muscle
coordination caused by damage to the brain before or at birth);
– Incontinent of bladder and occasionally incontinent of bowel.
Review of the resident’s quarterly MDS, dated , 7/20/18, showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility and transfers;
– Required extensive assistance of one staff for toilet use;
– Frequently incontinent of urine;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 10/18/18, at 9:45 A.M., showed:
– CNA A and CNA B used the sit to stand lift (raises the resident to a partial or full
standing position) and transferred the resident from his/her wheelchair to the toilet;
– CNA A removed the resident’s wet incontinent brief and CNA B lowered the resident onto
the toilet;
– CNA A raised the resident up from the toilet;
– CNA B wiped from front to back five times with fecal material on each wipe;
– CNA B wiped from front to back one more time without fecal material on the wipe;
– CNA B wiped down one side of the groin, used a new wipe and wiped down the other side of
the groin;
– CNA B did not separate and thoroughly cleanse the front perineal folds;
– CNA B did not clean the buttocks of hips.
During an interview on 10/19/18, at 9:30 A.M., CNA B said:
– He/she should have separated and cleaned all the perineal folds;
– He/she should have cleaned all areas of the skin where urine had touched.
5. Review of Resident #154’s care plan, dated, 4/8/18, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
– The resident was independent with ADL’s, grooming and hygiene;
– Required set up assistance /supervision at times;
– The resident will be clean, dry and odor free;
– Provide set up assistance /encouragement/ cueing as needed/requested for ADL’s, grooming
and hygiene.
Review of the resident’s quarterly MDS, dated , 9/22/18, showed:
– Cognitive skills intact;
– Supervision required for personal hygiene;
– [DIAGNOSES REDACTED].
Observation and interview on 10/16/18, at 12:52 P.M., showed:
– The resident had several chin whiskers at least a quarter of an inch in length;
– The resident said he/she would like to be shaved more often, he/she was lucky if it was
done at least once a week;
– He/she really wanted it done before he/she had her next dentist appointment;
– It bothered him/her to have the chin whiskers and was sure it bothered other people.
During an interview on 10/19/18, at 9:04 A.M., CNA A said:
– The resident required set up with showers;
– The staff assisted the resident when he/she requested to bed shaved.
6. During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said:
– Staff should remove facial hair per the resident’s preferences;
– Staff should assist the resident remove facial hair when visible;
– Staff should separate and cleanse all perineal folds when they provided incontinent
care;
– Staff should clean all areas where urine or feces touched the skin.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure staff
transferred residents with a mechanical lift in a safe manner to prevent the possibility
of injury. This affected two of 34 sampled residents (Resident #125 and # 37). The
facility census was 170.
1. Review of the manufacturer’s Operating Manual for the Invacare Electric Portable
Patient mechanical lift shows:
– Warning: Do not lock the rear casters of the patient lift when lifting an individual;
– Locking the rear casters could cause the patient lift to tip and endanger the patient
and assistants.
Review of the manufacturer’s User Manual for the Invacare Stand Up Patient Lift, showed:
– Warning: Invacare does not recommend locking the rear casters of the Stand Up Lift when
lifting and transferring an individual the patient and assistants;
– Invacare recommends that the rear casters be left unlocked during lifting and
transferring procedure to allow the stand up lift to stabilize itself when the patient is
initially lifted from and transferred to a chair, bed, or any stationary object.
2. Review of Resident #125’s Minimum Data Set, (MDS) a federally mandated assessment
instrument completed by facility staff, dated 6/10/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
– Able to make daily decisions;
– Dependent on staff for transfers.
Review of the resident’s care plan, updated 9/7/18, showed:
– Two staff assist transfer the resident with (Hoyer) mechanical lift.
Observation on 10/19/18 at 2:15 P.M., showed the resident sat in his/her wheelchair on a
mechanical lift sling. Certified Nurse Aide (CNA) H and CNA I transferred the resident
from his/her wheelchair to his/her bed. CNA I opened the legs of the lift and placed the
lift around the resident’s wheelchair, CNA I locked the rear casters of the mechanical
lift. Staff attached the sling to the mechanical lift. CNA I used the electric control and
lifted the resident from the wheelchair, unlocked the brakes and wheeled the resident to
his/her bed, positioned the resident over the bed and lowered the resident to the bed.
During an interview on 10/19/18 at 2:40 P.M., CNA I said:
He/she opened the legs of the lift around the wheelchair and felt most comfortable to
leave the legs open under the resident’s bed;
He/She locked the rear castors of the lift, hooked the sling up to the lift and lifted the
resident;
– He/she unlocked the rear castors to move the resident.
3. Review of Resident #37’s quarterly MDS, dated , 7/20/18, showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility and transfers;
– Required extensive assistance of one staff for toilet use and personal hygiene;
– Frequently incontinent of urine;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated, 9/12/18, showed:
– The resident used a Hoyer lift with the assistance of two staff for transfers.
Observation on 10/18/18 at 9:45 A.M., showed:
– CNA A removed the foot pedals from the wheelchair;
– CNA A and CNA B locked the wheelchair and placed the lift pad around the resident and
fastened it;
– CNA B opened the legs of the lift to go around the wheelchair and CNA A and CNA B hooked
the resident up to the lift;
– CNA B moved from the resident’s wheelchair to the toilet with the legs of the lift open,
locked the rear casters on the sit to stand lift, and lowered the resident onto the
toilet.
During an interview on 10/19/18, at 9:04 A.M., CNA A said:
– The brakes are supposed to be locked when we raise the resident up or lower the
resident.
During an interview on 10/19/18, at 9:15 A.M., CNA B said:
– The brakes are locked on the sit to stand lift when we raise or lower the resident.
4. During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said:
– During transfer with the mechanical lifts, staff should lock the rear castors on the
mechanical lift before they raised and lowered the resident and unlock the castors when
moving the resident.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to provide care
to prevent urinary tract infections [MEDICAL CONDITION] for two residents (Residents #152
and #167). The facility census was 170.
1. Review of the facility policy, dated 4/6/17. on perineal (peri) care showed:
– Staff must clean the resident’s genital and rectal area.
– If a resident had retractable perineal folds, staff must retract the resident’s perineal
folds, clean underneath them, dry the folds, and replace the folds.
– Staff must clean the anal area as well.
2. Review of Resident #152’s care plan showed:
– 7/2/18 the resident had incontinence with occasional [MEDICAL CONDITION] and staff must
provide pericare after each incidence of incontinence.
– 8/18/18 Bactrim DS (an antibiotic) two times a day for 10 days to treat a UTI.
– 9/11/18 Staff to [MEDICATION NAME](an antibiotic) and start [MEDICATION NAME] (an
antibiotic) and Azo (used to treat urinary pain).
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 9/22/18, showed:
– Cognitively intact;
– Required extensive staff assistance for transfers, toileting, and hygiene;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel.
Observation on 10/17/18 at 1:48 P.M. of Certified Nurse Assistant (CNA) K and CNA L
providing peri care for the resident showed:
– The resident had retractable perineal folds.
– CNA K retracted the resident’s perineal folds and cleaned between them.
– He/she did not dry the perineal folds.
– He/she did not replace the perineal folds.
– He/she did not clean the resident’s anal area.
During an interview on 10/17/18 at 1:50 P.M. both CNAs said:
– They did not know how to provide peri care for a resident with retractable perineal
folds.
– They should have cleaned the resident’s anal area.
During an interview on 10/17/18 at 1:50 P.M. the Director of Nursing (DON) said:
– If a resident had retractable perineal folds, staff must retract the folds, clean under
the folds, dry the area, and then replace the folds.
– Staff must clean the resident’s anal area.
3. Review of Resident #167’s annual MDS, dated [DATE], showed:
– Cognitively intact;
– Independent for toileting;
– Continent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan showed on 10/1/18 staff should assist the resident with
drinking at least 60 ounces of water a day.
Review of the resident’s physician order sheet (POS) dated (MONTH) (YEAR), showed:
– His/her physician recommended the resident drink 60 ounces of water a day.
– An order on 10/8/18 an order for [REDACTED].>- AN order on 10/9/18 [MEDICATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
NAME](an antibiotic) to treat a UTI.
Review of the resident’s medical records showed staff did not monitor the resident’s fluid
intake.
Observations of the resident in the dining room on 10/16, 10/17, and 10/18 showed the
resident had two 8 ounce glasses of fluids that he/she drank at each meal.
During an interview on 10/17/18 at 1:50 A.M. the DON said staff should ensure the resident
drank enough water.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record reviews, the facility failed to provide
documentation that the consultant pharmacist (PharmD) performed monthly drug regimen
reviews (DRR). The facility failed to provide documentation that the PharmD identified any
attempts requesting a gradual dose reduction (GDR) in an effort to reduce or discontinue a
resident’s psychoactive (medications that alter brain function) and also failed to provide
documentation that the resident’s physicians were provided with this information in a
timely manner. Staff did not document on-going monitoring of adverse drug reactions. This
affected four of 39 residents (Residents #3, #20, #55 and #146). The facility census was
170.
1. Review of the facility policy, dated 4/7/17, on medication administration showed:
– The PharmD will review each resident’s drug regimen on a monthly basis.
– All PharmD recommendations will be given to the Director of Nursing (DON) and the
resident’s physician.
– All PharmD recommendations will be addressed and followed up by nursing and/or the
resident’s physician.
– Each resident’s psychoactive medications will be reviewed by the resident’s physician
and nursing on a quarterly basis.
2. The facility did not provide Resident #3’s abnormal involuntary movement scale (AIMS) (
a scale to help staff monitor adverse reactions to psychoactive medications).
Review of the resident’s care plan, dated 9/7/18, showed:
– The resident was at risk for adverse effects from psychoactive medications taken for
substance abuse, dementia, [MEDICAL CONDITION], impulse disorder, anxiety, and depression.
– PharmD to routinely review medications and ensure all recommendations sent to the
resident’s physician.
– Nursing to assist the resident’s physician.
– A handwritten unsigned note dated 9/7/18 on the care plan stating the resident’s Nurse
Practitioner (NP) said Gradual dose recommendation no recommended due to the potential
risk of returning [MEDICAL CONDITION]-at baseline.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/5/18, showed:
– Mild cognitive impairment;
– No behaviors noted;
– No mood disorders noted;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
– [DIAGNOSES REDACTED].
– Took antipsychotic and antidepressant medications.
Review of the resident’s physician order sheet (POS), dated (MONTH) (YEAR), showed:
– An order, dated 4/5/17, for [MEDICATION NAME] 20 milligrams (mg) orally (PO) daily for
major [MEDICAL CONDITION];
– An order, dated 4/5/17, for [MEDICATION NAME] 1 mg po twice daily for abnormal
movements;
– An order,, dated 4/5/17, for [MEDICATION NAME] 20 mg po twice a day for [MEDICAL
CONDITION];
– An order, dated 4/5/17, for topirmate 100 mg po twice a day for [MEDICAL CONDITION];
– An order, dated 4/5/17, for [MEDICATION NAME] 500 mg po three times a day for impulse
disorder;
– An order, dated 4/5/17, for [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 50 mg
injections given monthly, no indication given.
3. The facility did not provide an AIMS for Resident #20.
Review of the resident’s annual MDS, dated [DATE], showed:
– Cognitively impaired;
– No behaviors noted;
– No mood disorders noted;
– [DIAGNOSES REDACTED].
– Received antipsychotic, antidepressant, and antianxiety medications.
Review of the resident’s care plan, dated 10/15/18, showed:
– The resident was a fall risk due to side effects of medications.
– The resident was at risk for adverse side effects due to psychoactive medications,
– Staff must perform an AIMS at least quarterly.
– PharmD to review medications routinely.
– PharmD recommendations to be sent to the nurse (did not specify which nurse) for
possible GDRs.
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– An order, dated 4/1/16, for trazadone 75 mg po at HS to be given for mood disorder;
– An order, dated 3/8/18, for [MEDICATION NAME] 0.5 mg po twice a day for abnormal
movements.
4. The facility did not provide Resident #146’s AIMS.
Review of the resident’s care plan,dated 4/7/18 showed:
– Staff should perform an AIMS quarterly and as needed;
– PharmD to routinely monitor the resident’s medications.
– A handwritten note, dated 8/17/18 No GDR recommendation this time per the resident’s
physician.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Mild cognitive impairment;
– No abnormal moods noted;
– No behaviors noted;
– [DIAGNOSES REDACTED].>- Received antipsychotic and antidepressant medications.
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– An order, dated 2/7/13, ,for citalopra 40 mg po to be given daily for major [MEDICAL
CONDITION];
– An order, dated 12/8/14, for [MEDICATION NAME] 2 mg po to bee given for abnormal
movements;
– An order, dated 5/29/14, for [MEDICATION NAME] 20 mg po to be taken twice a day for
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
[MEDICAL CONDITION];
– An order, dated 11/3017, for [MEDICATION NAME] 100 mg po at HS for [MEDICAL CONDITION];
– An order, dated 3/1/15, for [MEDICATION NAME] 100 mg to be given by injection once a
month for paranoid [MEDICAL CONDITION].
Observation on 10/16/18 at 4:11 P.M. showed the resident continually rolling his/her
fingers and total body shaking (a possible side effect of psychoactive medications).
5. During an interview and record review on 10/19/18 at 6:00 P.M. the Director of Nursing
(DON) said:
– The PharmD reviewed each resident medications on a monthly basis.
– He/she communicated the PharmD’s recommendations to the residents’ physicians.
– The DON did not provide the surveyor PharmD DRR and GDR recommendations for the
requested resident.
– The DON did not provide any AIMS.
6. Review of Resident #55’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– No mood disorder noted;
– Rejected care at least one to three times during the look back period;
– [DIAGNOSES REDACTED].
Took antipsychotic, antianxiety and antidepressant medications.
Review of the resident’s care plan, last updated 8/3/18, showed:
– Assess for any mood/behavioral changes as needed
– Administer medication as ordered;
– Observe for adverse side effects, document and report to physician;
– Pharm D review/consult on medications routinely and as needed with all recommendations
sent to physician for review.
Review of the resident’s (MONTH) (YEAR) physician order sheet, showed:
– Ordered 2/3/17 aripiprazole (treat [MEDICAL CONDITION])10 mg daily;
– Ordered 2/3/17 [MEDICATION NAME] (antidepressant) 30 mg daily;
– Ordered 2/3/17 [MEDICATION NAME] (treat major [MEDICAL CONDITION]) 75 mg daily;
– Ordered 5/17/18 [MEDICATION NAME] (antidepressant) 100 mg three times daily;
– Ordered 8/28/18 [MEDICATION NAME] (antianxiety) 0.25 mg at bedtime.
During an interview on 10/19/18 at 9:41 A.M., the assistant Director of Nurses (ADON)
said:
– Responses from the resident’s physician for the Pharm D recommendatons were kept in a
separate notebook;
– He/she did not have permission from the administrator to allow surveyors to see the
notebook.
During and interview on 10/19/18 at 2:51 P.M., the ADON stated the Drug Regimen Review
(DRR) and Gradual Dose Reduction (GDR) reviews requested earlier that morning, remained in
the DON office, the DON was still working on them.
He/she did not provide the requested PharmD DRR/GDR recommendations or physician responses
for any requested resident.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
Based on observations, interviews, and record reviews the facility failed to ensure staff
administered medications with a less than 5% medication error rate. Staff made two errors
out of 32 opportunities for error which resulted in a 6.25% error rate. This affected
three residents (Residents #71, #146). The facility census was 170.
1. Review of the facility policy, dated 4/6/17, on medication administration showed:
– Staff must administer medications the right time.
– Staff must administer medications the right dose and dosage form.
– Staff must schedule medication administration times to best reflect the physician’s
orders and drug recommendations.
– Medications that are to be given with food, will be given within 30 minutes before or 30
minutes after the meal consumption;
– If the medications must be given with food, and it is out of the 30 minute window, then
a small snack will be provided to the resident to prevent GI upset, according to their
diet.
– Staff should give residents a snack for medications that should be administered with
food to prevent gastric distress.
Review of the undated Prescribing Digital Reference on polyethylene [MEDICATION NAME]
showed:
– The medication was used to treat constipation.
– The medication worked by drawing fluid from the body into the stool for ease of bowel
movements.
– The medication must be mixed with four to eight ounces of liquid.
2. Review of Resident #146’s physician order sheet (POS), dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
– an order for [REDACTED].
Observation on 10/17/18 at 9:03 A.M. of Certified Medication Technician (CMT) A administer
medication to the resident showed:
– He/she put 17 GM of polyethylene [MEDICATION NAME] in a small glass and added about two
ounces of water.
– He/she then added 15 ml of [MEDICATION NAME] to the mixture.
– He/she gave the medications to the resident.
– He/she added water to the empty glass and found the glass held three ounces of water and
four ounces when filled to brim of the glass.
During an interview on 10/17/18 at 9:03 A.M. CMT A said:
– He/she did not know that the glass only comfortably held three ounces of water.
– He/she thought it was alright to add the [MEDICATION NAME].
– He/she thought he/she should mix polyethylene [MEDICATION NAME] with at least four
ounces of liquid.
3. Review of the undated WebMD website on [MEDICATION NAME] showed:
– The medication was used for pain and fever relief.
– Normal dosage for the medication was 400 milligrams (mg) to 800 mg;
– The medication could cause gastric distress;
– To lessen gastric upset, the medication should be administered with food.
Review of Resident #71’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Observation on 10/19/18 at 11:45 A.M. of CMT B administering medication to the resident
showed:
– He/she administered 400 mg [MEDICATION NAME].
– He/she did not give the resident any food.
– The resident was waiting for lunch.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
Observation on 10/19/18 at 12:15 P.M. showed facility staff served the resident a glass of
milk,
During an interview on 10/19/18 at 12:15 P.M. CMT B said:
– Did not realize that the resident should have food with [MEDICATION NAME].
– He/she did not realize the resident should have 800 mg of [MEDICATION NAME].
During an interview on 10/19/18 at 12:15 P.M. the DON said:
– He/she thought the residents did not need food with [MEDICATION NAME].
– Staff should administer the correct dosage of medication.
– Staff should administer polyethylene [MEDICATION NAME] in at least four ounces of water.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure staff
labeled when opened multi-use vials, which affected two residents (Residents #114, #167).
Additionally, staff failed to discard expired medications, and failed to discard opened
single use medications. The facility failed to ensure staff followed their policy for
staff checking medication rooms and carts. The facility census was 170.
1. Review of the facility policy, dated 4/6/17, on medication cart monthly inspections
showed:
– The charge nurse on the night shift would complete a monthly review of all medication
and treatment carts the last Saturday of each month.
– The night charge nurse must check medications for outdates and destroy any outdated
medications.
Review of the package insert, dated (MONTH) 2007, for [MEDICATION NAME] showed:
– The medication was used to treat elevated blood sugar.
– Staff must date all vials when opened.
– Staff must discard all opened vials 28 days after opening.
Review of the package insert, dated (MONTH) 2012, for Novalog insulin showed:
– The medication was used to treat elevated blood sugar.
– Staff must date all vials when opening.
– Staff must discard all opened vials 28 days after opening.
2. Observation 10/18/18 at 7:12 A.M. of the medication storage room on the Homestead Unit
showed:
– Resident #167’s opened, dated 9/1/18, vial of Novalog insulin;
– Resident #114’s opened, undated, vial of [MEDICATION NAME];
– Two vials of injectable hydrozyxine (used to treat anxiety and allergies [REDACTED].
– An opened vial of sterile water for injection (used to mix medications), dated 9/22/18,
with a label stating for single time use only;
– An opened, undated 10 milliliters (ml) vial of [MEDICATION NAME] (a numbing medication)
with a label stated for single use only;
– An opened, undated vial of [MEDICATION NAME] (used to treat [MEDICAL CONDITION]), with a
label stating single use only.
Observation on 10/18/18 at 2:30 P.M. of the crash cart on the Homestead emergency crash

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
cart showed:
– A bottle of saline eye wash with an expiration date of 4/1/14;
– Three 100 ml bottles of saline with an expiration date of (YEAR).
During an interview on 10/18/18 at 3:00 P.M. the Business Office Manager (BOM) said:
– He/she checked the facility crash carts daily for completeness.
– He/she did not know he/she should check the crash carts for outdates as well.
During an interview on 10/18/18 at 9:00 A.M. the Director of Nursing said:
– One of the nursing administration checks the medication rooms and medication carts twice
a week.
– Staff did not have a check list for checking the medication rooms.
– The BOM checks the crash carts daily.
– Staff must label all insulins when opened and discard according to manufacture’s
instructions.
– Staff must discard all expired medications.
– Staff must not reuse single dose vials.
3. Observation and interview on 10/17/18, at 3:19 P.M., of the medication room on the 800
hall showed:
– Resident #372 had a plastic bag with his/her name on it which contained his/her birth
certificate, a piece of paper with a copy of a non driver’s license card on it, seven one
dollar bills, and $6.79 in change and CMT C said it looked like the resident’s EBT card.
CMT C said the items should not be stored in the medication room;
– Resident #63 had a vial of [MEDICATION NAME] (used to treat [MEDICAL CONDITION]), 125
mg./5 ml., IM every 14 days, did not have a date when it was opened;
– CMT C said the medication should be dated when it was opened.
Observation and interview on 10/18/18, at 6:46 A.M., of the Meadow Brook hall medication
room showed:
– Resident #48 had a bottle of sterile saline used for injection and did not have a date
when it was opened;
– Resident #105 had one bottle of sterile saline used for injection and did not have a
date when it was opened;
– House stock of [MEDICATION NAME] suppositories (laxative), 10 mg. had five plus one that
was out of the container and expired 8/2018;
– The Assistant Director of Nursing (ADON) said the vials should have a date when they
were opened. Staff should not use expired medications. Staff are to take the expired
medications to the DON and herself and they destroy them.
Observation on 10/18/18, at 3:01 P.M., of the emergency crash cart on the 800 hall,
showed:
– Two bottles of sterile saline, expired 7/2017;
– One container of bleach sanitizer cloth, expired 9/2017.
During an interview on 10/19/18, at 5:52 P.M., the DON said:
– The CMT or the nurse notify the DON when the medications need to be destroyed;
– Staff should not use expired medications;
– The nurse or CMT’s should be checking expirations in the carts also.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on observations, interviews, and reviews, the facility failed to honor resident
preferences for meals. The facility census was 170.
1. Record review on 10/17/18 at 7:50 A.M. of the posted menu for the Homestead Unit
10/17/18 for breakfast showed:
– Scrambled eggs;
– Toast with butter;
– Oatmeal or cold cereal of choice.
Observation on 10/17/18 at 7:50 A.M. of the dining room on the Homestead unit showed:
– Without asking residents what they wanted to eat, staff served residents plates from
kitchen containing a small scoop of scrambled eggs, one piece of toast and jelly, and a
bowl of oatmeal.
– Dietary did not send any cold cereal or butter.
During a group interview with residents from the Homestead unit and the Meadowbrook unit
on 10/17/18 at 10:05 A.M. the group said:
– They could not request an alternative after the food arrived.
– Often, dietary did not send the items listed on the menu.
– They discuss dietary issues at council meetings but their issues were never resolved.
missed a meal, staff did not ask if they wanted anything to eat.
– Often dietary staff made menu substitutes.
– Staff always served cold toast and often did not serve butter or jelly with the toast.
– They have complained about often no butter for the toast.
Record review on 10/18/18 at 7:50 A.M. of the breakfast menu for the Homestead Unit
showed:
– Scrambled eggs;
– Cinnamon toast;
– Hot cereal or cold cereal of choice.
Observation on 10/18/18 at 7:50 A.M. of the dining room on the Homestead unit showed:
– Without asking residents what they wanted to eat, staff served residents plates prepared
in the kitchen containing a small scoop of scrambled eggs, one piece of plain toast and
jelly, and a bowl of oatmeal.
– Dietary did not send any cold cereal.
During an interview on 10/18/18 at 7:50 A.M. Certified Nurse Assistant (CNA) C said:
– He/she usually worked on the Homestead unit.
– Staff offered beverage choices with every meal.
– Dietary staff did not send any breakfast alternatives.
– Staff just served what dietary sent.
During an interview on 10/18/18 at 7:53 A.M. Resident #135 said:
– He did not like the facility served breakfast.
– He would like cold cereal and omelets.
During an interview on 10/18 at 7:53 A.M. Resident #145 said:
– The facility always served the same thing for breakfast.
– He/she would like to have some choices for breakfast.
– He/she did not like cereal but received cereal every morning.
– He/she would like pancakes and biscuits and gravy.
During an interview on 11/19/18 at 6:00 P.M. the Director of Nursing (DON) and Assistant
Director of Nursing (ADON) said:
– They did not know that the residents were not being offered substitutes.
– All the units should have cold cereal and milk.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review the facility failed to follow menus, or
offer substitutes of equal nutritional value and failed to obtain the Registered
Dietitian’s (RD) menu approval. The facility census was 170.
1. Review of the facility Menu and Diet Guidelines policy showed the facility dietitian
(RD) should review and sign the menu and menu components prior to implementation in order
to ensure state regulations as well as facility policies and procedures are met.
Review of the facility Cycle Menus Policy showed:
– Menus are implemented by the Dietary Manager (DM) in conjunction with the RD.
– The menus are three-meal plus a snack.
– When changes in the menu are necessary, the changes must provide equal nutritive value.
Menu changes are made on the menu (posted in Dietary) for regular and therapeutic diets
before the meal is served, or on the Substitution List. Menu changes are reviewed and
approved in advance by the DM.
– Menus must be followed as written.
Review of the facility Making Menu Substitutions policy showed that when substitutions are
made, the replacement item must be compatible with the rest of the meal, comparable in
nutritive value and reviewed by the DM for appropriateness.
2. During observation, interview and record review on 10/16/18 at 1:59 P.M., Cook A showed
a food alternates menu posted on the side of the kitchen refrigerator. Cook A said the
list of alternates were standard for all meals. Review of the POS [REDACTED].
During observation, interview and record review on 10/18/18 at 9:33 A.M.,
– Cook A, Cook C and DA A said they did not think the limited choices of the facility food
alternates equaled the comparative value of scheduled menu foods.
3. Record review on 10/18/18 at 6:03 A.M., showed the breakfast menu included choice of
hot or cold cereal and cinnamon toast.
Observation, interview and record review on 10/18/18 at 9:33 A.M., showed kitchen staff
did not prepare cinnamon toast as scheduled on the planned menu. DA A said he/she did not
make cinnamon toast as they probably did not have cinnamon. DA A then hunted for cinnamon
and found a small amount in a container. DA A said this would not have been enough
cinnamon for the number of residents they serve. Cook C confirmed that the amount of
cinnamon DA A found would not have been enough. Review of the scheduled menu showed it was
not updated to show a change from cinnamon toast to buttered toast. DA A said he/she did
not update the menu showing the change.
During an interview and record review on 10/18/18 at 10:05 A.M., DA A showed and said the
planned scheduled menu was for a choice of hot or cold cereal to be served every day for
breakfast. Review of the menu confirmed staff were to serve both hot and cold cereal
daily. DA A said that instead of preparing both hot and cold cereal daily, they alternated
by sending cold cereal one day and hot the next.
4. Observation on 10/18/18 at 7:07 P.M., showed:
– Six residents still in the dining room.
– Some residents had noodle soup, some had vegetable.
-Some residents had cake some had fruit cups.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
– Three of six residents had cornbread and three had a salad.
In an interview on 10/18/18 at 7:15 P.M., Cook B said they should have had chili tonight
but they had it for lunch with the residents’ choice meals. He/she fixed chicken noodle
soup, ran out before all the residents that ate last were served so he/she opened a can of
vegetable soup. He/she had about 15 bowls of fruit but that was not enough to give every
resident in the group of residents that they served last, so she gave some of the
residents cake. The standard alternates for meals was salad, a sandwich or two bowls of
cereal.
5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said:
– Menus were not signed off on by a RD. There was no place for the RD to sign.
– She discovered her kitchen staff used an alternate choice list that had only three
choices listed. She did not know where the list came from or who created it. The three
alternate options the staff provided were not satisfactory as they did not provide equal
nutritional value when compared with scheduled menu foods.
– All residents should be offered a choice of either cold or hot cereal daily per the
scheduled menu. It was not satisfactory for kitchen staff to have alternated between the
two cereals.
– On 10/18/18, kitchen staff should have offered the scheduled menu cinnamon toast. If
running low, she would have obtained more cinnamon.
– Staff should check before meal preparation to assure they are able to provide what is
scheduled on the menu. If scheduled menu items are not available staff were to follow the
procedure for substitutions.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observations, interviews and record review the facility failed to preserve food
quality when staff did not check food temperatures at the time of meal service or store
food in a method to maintain food quality. The facility censes was 170.
1. Review of the facility Food Temperatures policy showed:
– Foods will be served at proper temperature to insure food safety.
– Record reading on Food Temperature Chart form at beginning of tray line and during the
tray line. If temperatures do not meet acceptable serving temperatures, reheat the product
or chill the product to the proper temperature. Take the temperature of each pan of
product before serving.
2. During an interview on 10/17/18, at 9:45 A.M.,in the main dining room Resident #35 said
the oatmeal is cold.
Observation on 10/18/18 at 7:44 A.M., showed breakfast service in the Homestead dining
room. Residents complained breakfast was cold.
Observation and record review on 10/18/18 at 8:37 A.M., showed:
– No staff took temperature of the breakfast foods prior to meal service.
– Review of the log to record food temperatures showed no temperatures were recorded.
– Dietary Aide A said he/she did not have time to take food temperatures. He/she was
supposed to check the food temperatures when the food was placed on the steam table and
again after three food trays were served.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
– Cook A said staff were to check food temperatures when food was placed on the steam
table and again at mid service. Foods temperatures were not checked today.
3. Observation on 10/18/18 at 7:56 A.M., showed 8 food trays left on cart for residents on
the Rothman Senior unit. The dietary aide took the trays to the snack room. The trays were
left in the snack room with no warmer or cover on the oatmeal.
Observation on 10/18/18 at 8:43 A.M. showed 7 of the 8 food trays still sitting in the
snack room.
During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was
the unit manager, said food trays should not be left in the snack room for residents who
slept during meal service. Staff were to get food from the kitchen for residents who
wanted to eat when they woke up.
During an interview on 10/19/18 at 5:30 P.M., the administrator said staff should not
serve food to residents that has been left out in room temperature. If residents did not
come to retrieve their food tray, the trays were to be sent back. It was not okay for
staff to let food trays sit out.
4. Observation of the Rothwell and Rothwell Senior unit on 10/19/18 at 12:00 P.M., showed:
– At 12:00 P.M., staff delivered covered meal trays on a cart to the unit dining room.
– At 12:20 P.M., a resident stated the food is going to be cold by the time we get it. It
has been sitting there for 20 minutes.
– At 12:22 P.M., one staff person began serving the meal trays without checking the food
temperature.
During an interview on 10/19/18 at 5:30 P.M., LPN A said he/she expected staff to serve
residents in the unit dining room within twenty minutes of the time the food was
delivered.
5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said:
– Staff should check food temperatures to assure proper temperatures are met for each meal
service.
– It was not acceptable for the Rothwell and Rothwell Senior unit food to sit out on the
tray cart for twenty minutes before staff served residents. In that amount of time the
food will lose temperature required for meal service. The unit needed a steam table to
assure proper temperatures are maintained.
– When residents sleep in, they should be offered breakfast when they wake up. Breakfast
foods including cereal, sausage and instant oatmeal should be offered. It was not
satisfactory for food trays to sit out while the residents slept. Food sitting out losses
proper temperature. Food sitting out for twenty minutes should be discarded. When the
resident wakes up nursing staff should come to kitchen and get a new tray for the
resident.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to ensure

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
staff offered each resident a bedtime snack (HS).This had the potential to affect all
facility residents. The facility census was 170.
1. Review of the facility Snacks and House Supplements policy showed:
– House snacks provide additional calories and meet a resident’s individualized
nutritional and care plan needs. Food is to be handled employing all proper safe food
handling practices.
– HS snacks should provide a minimum of a starch or bread serving and fruit drink.
Review of the facility Snacks policy showed:
– Daily snacks are provided in accordance with the prescribed diet and in accordance with
state law. Individual and/or bulk snacks are available at the nurses’ station for
consumption by residents whose diet orders are not restrictive.
– Procedure includes at least one serving or a minimum of two of the following four food
components is offered for the bedtime snack:
1. Fruit and/or vegetable or full-strength fruit or vegetable juice.
2. Whole Grain or [MEDICATION NAME] cereals or breads.
3. Milk or other dairy products.
4. Meat, fish, poultry, cheese, eggs, peanut butter.
Review of the facility Cycle Menus Policy showed:
– Menus are implemented by the Dietary Manager (DM) in conjunction with the Registered
Dietitian (RD).
– The menus are three-meal plus a snack.
2. During a group interview on 10/17/18 at 10:05 A.M. with residents from the Homestead
and Meadowbrook units the residents said:
– The units often do not have HS snacks.
– Staff never delivered HS snacks.
– If a resident did not go to the desk and request a snack, staff did not offer the
resident a snack.
Observation on 10/18/18 at 7:13 P.M. of the Homestead Unit kitchen showed:
– A large bag of crisp rice cereal;
– No milk for the cereal;
– Six containers of chocolate pudding.
During an interview on 10/18/18 Certified Nurse Assistant (CNA) D said:
– The unit did not have any HS snacks.
– Dietary always sent fresh HS snacks on the evening meal cart.
– He/she forgot to remove the snacks from the cart.
– He/she would go to the kitchen and get snacks.
Observation on 10/18/18 at 8:15 A.M. of the Homestead unit showed:
– Several residents coming to the nurses station for a snack.
– No staff offering snacks to the residents in their rooms.
During an interview on 10/18/18 at 8:15 P.M. Licensed Practical Nurse (LPN) B said:
– He/she was the unit manager for the Homestead Unit.
– Residents could come to the nurses station and request a snack.
3. In an interview on 10/18/18 at 7:15 P.M., Cook B said he/she sent HS snacks on carts to
the facility units. He/she sent oatmeal cookies and some sandwiches for resident with
[DIAGNOSES REDACTED]. He/she looked for a list of residents on diabetic diets but was
unable to find it.
Observation on 10/18/18 at 7:30 P.M., of the snack room on the Meadowbrook unit showed no
sandwiches as described by the cook.
During an interview on 10/19/18 at 4:05 P.M. CNA N ,who worked on the Meadowbrook unit the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
evening of 10/18/18, said no HS sandwiches were received from the kitchen to Meadowbrook
before 7:30 P.M
. During an interview on 10/16/18, at 11:46 A.M., Resident #159 said:
– If we want a snack at bedtime, we have to go and see the hall monitor;
– The staff do not bring snacks to our room
. During an interview on 10/17/18, at 8:12 A.M., Resident #119 said:
– The staff do not bring snacks to our rooms;
– If we want a snack, we have to go and get it.
During resident council on 10/17/18 with 17 residents from the Rothwell, Rothwell Senior,
Parkwood and Parkwood Senior unit the residents said the facility does not offer the
residents bedtime snacks.
During an observation on 10/18/18 at 7:07 PM on the Parkwood and Parkwood Senior hall
facility refrigerator had no snacks for the residents and the freezer was empty of any
snacks for the residents.
During an observation on 10/18/18 at 7:45 PM on the Rothwell and Rothwell Senior halls the
facility refrigerator was empty of any snacks for the residents.
4. During an interview on 10/18/19 at 8:15 P.M. the Director of Nursing (DON) said:
– Dietary provided HS snacks for the residents.
– If a resident wanted a snack, he/she could obtain one at the nurses station.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observations, interview and record review the facility failed to properly store
foods and provide a sanitary environment in the kitchen. The facility census was 170.
1. Review of the kitchen polices showed:
– Cleaning Schedules policy showed no process for cleaning the standing refrigerator or
standing fans.
– The facility showed no policy for proper food storage.
– The facility showed no policy showing staff were required to cover hair in the kitchen.

2. Observation and interview during the initial kitchen tour on 10/16/18 at 10:55 A.M.,
showed:
– The center kitchen refrigerator had cake, pudding and fruit with no date. Salad in the
refrigerator was not uncovered and exposed.
– Dietary aide (DA) A looked but could not locate a thermometer for the refrigerator. DA A
said the refrigerator should have a thermometer in order to monitor the temperature. The
undated food was from the previous night and should have been dated prior to storage.
Observation and interview on 10/18/18 at 6:03 A.M., showed:
– The center kitchen refrigerator had uncovered broth dated 10/9/18. A second container of
broth was dated 10/14/18. DA A said the broth should be covered and should have been
discarded three days after it was opened.
– Two standing fans next to the food preparation area covered with think dust that could
be removed with touch of finger.
3. Observations on 10/18/18 at 7:00 A.M. and on 10/19/18 at 4:43 P.M. of the kitchen,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265330

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

NORTH VILLAGE PARK

STREET ADDRESS, CITY, STATE, ZIP

2041 SILVA LANE
MOBERLY, MO 65270

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
showed:
– Certified Nurse Aide (CNA) M entered the kitchen with no facial net covering his beard
and mustache.
– DA B prepared and served food with no facial net covering his beard and mustache.
– Activity Aide (AA) A in the food preparation area during meal prep and Cook B had hair
exposed from underneath hair nets.
4. Observation on 10/18/18 at 7:30 P.M., of the snack room on the Meadowbrook unit showed
numerous food items in the snack refrigerator not covered, dated or labeled.
5. During an interview on 10/19/18 at 4:43 P.M., the Dietary Manager (DM) said:
– All food stored in refrigerators should be covered, dated and labeled. Staff should
discard the food products after three days.
– I was not acceptable to have dirty fans in the kitchen. The dirt particles on the fans
could blow debris on foods.
– All hair should be completely covered with hair and facial nets in the kitchen.

F 0923

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have enough outside ventilation via a window or mechanical ventilation, or both.

Based on observation and interview the facility failed to clean and maintain smoke room
ventilation. The facility census was 170.
1. Observation and interview on 10/18/18 at 2:15 P.M., showed no one smoking in the 800
hall smoke room. A black thick substance covered the smoke room vent. The room air smelled
heavy of smoke. The maintenance supervisor (MS) said he was scheduled to clean smoke vents
weekly but had not cleaned the 100, 500 and 800 hall smoke room vents in the past three
months. Other facility task occupied his time and prevented him from cleaning the vents.