Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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

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 provide a clean and comfortable
environment by failing to ensure furniture, fixtures, equipment and resident rooms were
clean and in good repair. The facility census was 57.
1. Observation on 08/07/18 at 1:55 P.M. of the nursing supply room showed a round ceiling
vent that was covered in a thick layer of dust.
Observation on 08/07/18 at 1:56 P.M. of the B hall mechanical room showed a 6 inch 6 six
inch ceiling vent that was covered in a thick layer of dust.
Observation on 08/07/18 at 2:03 P.M. of resident occupied C hall, just outside the
resident day room, showed a 4 inch by 4 inch ceiling vent that was covered in a thick
layer of dust.
Observation on 08/07/18 at 2:09 P.M. of occupied resident room [ROOM NUMBER] showed the
bathroom door had a softball sized hole in the door.
Observation on 08/07/18 at 2:10 P.M. in the hallway between resident room [ROOM NUMBER]
and the resident day room, showed a 6 inch by 8 inch ceiling vent was covered in a thick
layer of dust.
Observation on 08/07/18 at 2:17 P.M. of resident occupied C hall showed four, 4 inch by 4
inch ceiling vents in the hallway that were covered in a thick layer of dust.
Observation on 08/07/18 at 2:27 P.M. of the mechanical room on C hall showed a 6 inch by 6
inch ceiling vent covered in a thick layer of dust. Around the top of the furnace and the
air conditioning system on both sides of the room was black fuzzy debris all the way
around the ceiling. There was several spots of a black fuzzy debris on the wall next to
each unit.
Observation on 08/07/18 at 2:49 P.M. of the resident therapy room showed a 4 inch by 5
inch ceiling vent covered in a thick layer of dust.
Observation on 08/07/18 at 2:55 P.M. of occupied resident room [ROOM NUMBER] showed the
light above the sink did not work.
Observation on 08/07/18 at 2:58 P.M. of occupied resident room [ROOM NUMBER] showed the
ceiling light in the bathroom did not have a light cover.
Observation on 08/07/18 at 3:04 P.M. of occupied resident room [ROOM NUMBER] showed the
board under the sink area was not attached and was leaning against the sink drain.
Observation on 08/07/18 at 3:06 P.M. of occupied resident room [ROOM NUMBER] showed the
night light cover was missing. Observation also showed the drawer tracks on the resident’s
built-in dresser were broken so the drawers would not slide into the dresser frame.
Observation on 08/07/18 at 3:09 P.M. of the oxygen storage room showed a 5 inch by 5 inch
ceiling vent covered in a thick layer of dust.
Observation on 08/07/18 at 3:11 P.M. of the resident shower room between D and E hall
showed a 5 inch by 5 inch ceiling vent that was covered in a thick layer of dust.
Observation on 8/8/18 at 8:15 A.M. of room [ROOM NUMBER] showed the bathroom toilet base
caulk line was stained brown, the toilet bowl base was stained brown and the bathroom was
dimly lit.
Observation on 08/08/18 at 9:11 A.M. of the laundry area showed a 4 inch by 4 inch ceiling
vent that was covered in a thick layer of dust.
Observation on 8/8/18 at 10:45 A.M. of room [ROOM NUMBER] showed the bathroom contained a
brown stained toilet bowl base, a plate sized brown/black stain near the bathtub drain and
sticky soiled areas in the base of the bathtub. The bathtub outside edge had a brown
stained caulk line. The room baseboards and corners were soiled with dirt and the room

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 1)
sink faucet area was soiled and stained black.
During interview on 08/08/18 at 1:20 P.M., the maintenance supervisor said he was
responsible for cleaning the ceiling vents. He was not aware of the dusty vents or the
black fuzzy debris on the wall and ceiling in the mechanical room. He did not monitor the
vents. He was responsible to ensure all lights worked, all lights were covered, and the
resident dressers worked properly.
During interview on 08/08/18 at 1:58 P.M., the administrator said he expected all vents to
be clean and free of dust. He expected there to be no black fuzzy debris anywhere in the
building. He expected all lights to work, all lights to be covered, and for all the
residents’ dressers to be in good repair.
Observation on 08/10/18 at 12:11 P.M. showed the following:
-The baseboards throughout resident occupied rooms 300, 302, 303, 305, 307, and 309 were
discolored and dirty. The floors around the edge of the baseboards and the toilets were
dirty;
-The baseboards in the shared resident bathrooms between rooms [ROOM NUMBERS], and between
300 and 302, were discolored and dirty, and the floor around the toilet was discolored and
dirty;
-The floor tile at the entrance to the bathroom in resident room [ROOM NUMBER] was chipped
and pieces of the tile was missing;
-The bath tub in the bathroom in resident bathroom [ROOM NUMBER] had yellow stains around
the edge of the tub, a circular area in the center, and around the drain.
-The lower portion of the wood doors to the bathrooms between resident rooms [ROOM
NUMBERS], between resident room [ROOM NUMBER] and 311, and in room [ROOM NUMBER] were
discolored, broken and peeling.
During interview on 08/10/18 at 4:25 P.M., the maintenance supervisor said the maintenance
department was responsible for repairing the floors and the doors. He expected staff to
report broken doors and tiles that needed to be repaired. He expected doors and floors to
be in good repair.
During interview on 08/10/18 at 5:15 P.M., the housekeeping supervisor said the
housekeeping department was responsible for cleaning the resident rooms, bathrooms and
halls throughout the building. He/she would expect staff to clean around the baseboards
and toilets. The housekeeping supervisor verified the baseboards were not clean and the
bathtub in room [ROOM NUMBER] was not clean. He/she said the baseboards in those rooms
needed replaced and the floors around the walls and toilets needed to be cleaned. He/she
would expect the floors, baseboards and bathtub to be clean in all the resident rooms.
He/she would expect staff to report broken tile and holes in the doors and any repairs
that were needed in resident rooms.
Surveyor: Cordray, Terri

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 observation, interview, and record review, the facility failed to follow
professional standards of practice for four residents (Residents #16, #21, #211 and #212),
in a review of 16 sampled residents. Staff failed to obtain physician ordered daily
weights for two residents (Resident #211 and #212); failed to obtain Resident #21’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 2)
[MEDICATION NAME] (generic name Levetiracetam, anti-[MEDICAL CONDITION] medication) blood
levels (laboratory blood test) as physician ordered; and failed to appropriately transfer
Resident #16 during a Hoyer lift transfer (mechanical lift used for non-weight bearing
residents). The census was 57.
1. Review of the facility policy Hydraulic Lift (Hoyer lift), dated (MONTH) (YEAR), showed
the purpose was to enable one individual to lift and move a resident safely.
2. Review of the undated Invacare manual for Manual/Electric Portable Patient Lift showed
adjustments for safety and comfort should be made before moving the patient.
3. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility Manual
showed the following:
-A mechanical lift is a device used to lift and move residents who are unable to do so on
their own.
-Two people are needed to use this device safely;
-Follow manufacturer’s directions regarding safe use;
-Check for proper body alignment.
4. Review of Resident #16’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/12/18, showed the following:
-Cognitively intact;
-Total dependence of two staff for bed mobility and transfers;
-Functional range of motion-impairment of both lower extremities.
Review of the resident’s care plan, dated 6/25/18, showed the following:
-Problem: Bilateral lower extremity paralysis and need for extensive assist with all
activities of daily living and transfers;
-Approaches: Assist of two staff and Hoyer lift for transfers.
Review of the resident’s Physician Order Sheet (POS), dated 8/1/18 to 8/31/18, showed the
following:
-[DIAGNOSES REDACTED].
-Up with assist of two staff and Hoyer lift.
Observation on 8/8/18 at 3:19 P.M., showed the following:
-The resident sat on the Hoyer lift sling in his/her electric scooter in his/her room;
-The assistant director of nursing (ADON) and Certified Nurse Assistant (CNA) D entered
the room with the Hoyer lift and attached the resident’s sling to the mechanical lift;
-CNA D operated the remote as the resident was raised into the air. The ADON walked to the
other side of the bed. The resident hung freely as he/she was lifted and his/her left foot
hit the emergency stop button on the lift bar. CNA D then grabbed the resident’s lower
legs and attempted to move the resident’s feet to the other side of the center hydraulic
bar, scraping the resident’s bilateral feet on the bar. The resident yelled ouch. CNA D
lowered the resident into bed and backed the lift away from the bed;
-As ADON and CNA D rolled the resident to remove the sling pad, the resident complained of
his/her little toe, stating, It hurt when you lifted me. The ADON exited the room.
During interview on 8/9/18 at 5:05 P.M., CNA D said the following:
-He/she did know he/she scraped the resident’s feet against the lift bar, he/she did not
know the resident’s foot had hit the emergency button;
-He/she should have guided the resident’s feet around the bar instead of forcing them or
should have had a second staff pull the resident back away from the bar.
During interview on 8/10/18 at 2:00 P.M., the resident said he/she knew during the
transfer, his/her foot scraped the bar as he/she felt it and that’s why he/she yelled,
ouch.
During interview on 8/10/18 at 2:45 P.M , Licensed Practical Nurse (LPN) A said two staff
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 3)
should be present during a Hoyer transfer with one staff driving the lift, the second
guiding the resident, and both watching the feet to ensure there are no injuries.
During interview on 8/14/18 at 6:50 P.M., the director of nursing (DON) said two staff
should assist with Hoyer transfers. One staff should hold feet and ensure the resident
does not hit the lift or other surfaces and the second should be at the bedside to assist
the resident over the bed.
5. Review of Resident #212’s POS, dated 8/1/18, showed the following:
-[DIAGNOSES REDACTED].
-Check and record weight daily (original order dated 7/13/18).
Review of the resident’s daily weight sheet showed the following:
-Daily weights. Have medication technician give [MEDICATION NAME] (diuretic) for greater
than 4 pound weight gain;
-Weight on 8/2/18 was 262.2 pounds;
-Weight on 8/4/18 was 271.2 pounds, a 9 pound weight gain;
-No weights were recorded on 8/6, 8/7, 8/8 or 8/9/18.
Review of the resident’s Medication Administration Record [REDACTED].
During interview on 8/10/18 at 3:15 P.M., Certified Medication Technician (CMT) P said the
following:
-The day shift CNA on the resident’s hall was responsible for obtaining the daily weights;

-The CNA on the floor or the restorative aide were responsible for obtaining the weekly
weights. The activity director may also assist with obtaining these weights;
-Monthly weights are posted at the nurse’s station for staff to obtain as they have time.
During interview on 8/14/18 at 4:30 P.M., CMT P said the following:
-The medication technicians do not monitor parameters. The nurses monitor and then informs
them if medications need to be given;
-He/she had not given [MEDICATION NAME] to Resident #212 this month.
6. Review of Resident #21’s Physician Order Sheet (POS), dated 1/11/18, showed the
following:
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] [MEDICATION]) 50 milligrams (mg) twice daily;
-Obtain Levetiracetam ([MEDICATION NAME]) blood level every 90 days in January, April,
(MONTH) and November.
Review of the resident’s laboratory results, dated 1/16/18, showed the following:
-Levetiracetam level (laboratory test that determines the level of Levetiracetam in the
body, high levels of Levetiracetam can cause toxicity) was 23.60 (normal range 5.0-30.0);
-No documentation staff obtained the resident’s (MONTH) (YEAR) Levetiracetam blood level.
During interview on 8/14/18 at 9:15 A.M. and 12:00 P.M., the MDS coordinator said the
following:
-Laboratory results were left in the residents’ paper charts for one year. He/she checked
the laboratory computer system for results. The only Levetiracetam level drawn for the
resident was in (MONTH) (YEAR);
-The resident’s physician ordered Levetiracetam levels every January, April, (MONTH) and
November. Staff did not obtain the resident’s (MONTH) (YEAR) Levitiracetam level as
ordered.
7. Review of Resident #211’s POS, dated 8/1/18, showed the following:
-[DIAGNOSES REDACTED].
-Daily weights (original order dated 7/31/18).
Review of the resident’s daily weight sheet (kept in the nurse’s binder) showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 4)
following:
-Weigh resident daily. If gains more than three pounds in three days or five pounds in one
week, call the physician;
-Weight on 8/5/18 was 133.6 pounds;
-Weight on 8/10/18 was 138.4 pounds (difference of 4.8 pounds);
-No weights were recorded on 8/6, 8/7, 8/8 or 8/9/18.
8. During interview on 8/14/18 at 6:30 P.M., the DON said the following:
-Staff should administer resident’s medications as physician ordered;
-Staff should obtain resident’s laboratory tests as physicians ordered and report results
to the physicians;
-She would expect weights to be obtained as ordered by the physician and for nursing to
monitor when orders are attached for a weight loss/gain;
-Weights should be obtained every morning before meals.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure facility
staff provided three of 16 sampled residents (Residents #10, #18, and #110) and one
additional resident (Resident #8), who were unable to provide their own activities of
daily living, the necessary care and services to maintain good personal hygiene and
prevent body odor. The facility census was 57.
1. Review of the facility policy A.M. Care (Early Morning Care) dated (MONTH) (YEAR)
showed the following:
-Purpose was to provide cleanliness, comfort and neatness;
-Provide privacy, take the resident to the bathroom and provide perineal care, allow the
resident to brush teeth or brush teeth or dentures for the resident if he/she was not
able, wash resident’s face and hands and dry well and transport to the dining area.
2. Review of the facility policy Perineal Care dated (MONTH) (YEAR) showed the following:
-Purpose was to cleanse the perineum and prevent infection and odor;
-Female perineal care: separate legs and flex knees, if unable to do, have resident lie on
their side with legs flexed, make a mitt with a wet washcloth and apply soap, use one
gloved hand to stabilize and separate the inner skin folds and labia, with the other hand,
wash from front to back, rinse and pat dry;
-Male perineal care: separate legs and flex knees, if unable to do, have resident lie on
their side with legs flexed, make a mitt with a wet washcloth and apply soap, wash pubis
and penis, if uncircumcised, pull back foreskin of penis and wash, carefully dry and
return foreskin to normal position, make sure shaft of penis was dry;
-Turn resident away from you, use a new washcloth and wash around the anus, rinse and dry.
3. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH)
2001, showed the following:
-Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are
essential for physical and mental well-being of the resident, prevent infections in mouth,
remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in
mouth, thus food is more appetizing;
-Give oral care before breakfast, after meals, and also at bedtime;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 – Some

(continued… from page 5)
-Specific observations to make: tooth decay, any loose or broken teeth, red or swollen
gums, sores or white patches in the mouth or on the tongue, changes in eating habits, and
poorly fitting dentures;
-A clean mouth is very important to the physical and mental well-being of the resident.
Oral care can prevent infections, the buildup of plaque, and bad breath. It can even
influence the resident’s appetite. Remember to observe the resident during oral care to
identify potential problems.
4. Review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/29/18 showed the following:
-Short and long term memory problem;
-Severely impaired daily decision making ability;
-Required extensive assistance of two staff members with bed mobility, dressing and
toileting;
-Required extensive assistance of one staff member with personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan revised 8/2/18 showed the following:
-[DIAGNOSES REDACTED].
-The resident was incontinent of bowel and bladder. Staff should check the resident every
two hours and as needed for incontinent episodes, provide perineal care after each
incontinent episode and apply incontinence briefs while up in the wheelchair. The goal was
to keep the resident clean, dry and odor free at all times;
-The resident had right sided weakness due to a stroke and was dependent on staff for
Activities of Daily Living (ADLs). Staff should provide assistance with all ADLs and
shower the resident twice weekly. Goal was the resident clean, dry and well-groomed at all
times with staff performing ADLs.
Observation on 8/9/18 at 7:00 A.M. showed the following:
-The resident lay in bed on his/her back;
-Nurse Assistant (NA) R turned the resident to his/her side and the resident said he/she
was wet;
-The resident was incontinent of urine and stool;
-NA R obtained wet wipes and removed a small amount of soft feces from the resident’s anal
area, obtained a clean wet wipe and wiped the resident’s buttock areas. NA R did not wash
the resident’s urine soiled hips, thighs, frontal skin folds or perineal area;
-NA R turned the resident side to side and removed the resident’s urine soiled
incontinence brief;
-NA R dressed the resident and asked the resident if he/she would like a shower. The
resident shook head yes. NA R said you smell yourself too, I know you would like a shower;
-NA R transferred the resident to a wheelchair and combed his/her hair;
-NA R did not provide the resident oral care or wash his/her face.
During interview on 8/9/18 at 7:40 A.M. the resident said no staff rinsed his/her mouth or
washed his/her face this morning. He/she noticed this morning he/she had an odor and
needed a shower.
During interview on 8/9/18 at 2:35 P.M. NA R said the following:
-He/she changed the resident’s soiled briefs, removed the brief, wiped them down a little
and put on a clean brief;
-He/she did not know the proper way to provide incontinence care. He/she wiped them down,
put on a clean brief and got the resident up in the wheelchair.
5. Review of Resident #18’s significant change MDS dated [DATE], showed the following:
-Extensive assist of one staff for transfers, dressing and personal hygiene;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 – Some

(continued… from page 6)
-Wheelchair for mobility;
-Swallowing disorder: Coughing/choking.
Review of the resident’s care plan dated 5/2/18 and last revised 8/2/18, showed the
following:
-Problems: I have missing teeth and have chewing and swallowing difficulties. I am weak
and unsteady and require assist of one with my ADL’s;
-Goals: I will be assisted with my ADLs by staff and be clean and well groomed at all
times;
-Approaches: Assist of one for all ADLs.
Observation on 8/9/18 at 6:50 AM showed the following:
-The resident lay on his/her back in the bed:
-CNA K entered the room and prepared wash cloths. He/she performed personal cares, dressed
the resident, transferred him/her to a wheelchair and offered a wash cloth for the
resident to wash his/her face. The CNA did not offer to assist the resident with oral
care.
During interview on 8/21/18 at 2:32 P.M. CNA K said oral care should be offered in the
A.M.
6. Review of Resident #8’s quarterly MDS, dated [DATE], showed the following:
-Limited assist of one staff for bed mobility;
-Extensive assist of one staff for personal hygiene;
-Always incontinent of bladder and bowel.
Review of the resident #8’s care plan last revised 7/26/18 showed:
-Problem: Incontinent of bladder and bowel;
-Goal: I will be kept clean, dry and odor free at all times;
-Approaches: One assist of staff for personal hygiene. Provide perineal care after each
incontinent episode.
Review of the resident’s POS dated 8/1/18 included [DIAGNOSES REDACTED].
Observation on 8/9/18 at 5:50 A.M. showed the following:
-The resident lay in his/her bed;
-CNA M entered the room, prepared to perform perineal care, removed the resident’s urine
soiled incontinent brief;
-CNA M performed perineal care but did not cleanse the right buttock/hip area.
7. Review of Resident #110’s Admission MDS, dated [DATE] showed the following:
-Severely impaired cognition;
-Extensive assist of two for bed mobility;
-Extensive assist of one for personal hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s POS, dated 8/1/18 showed [DIAGNOSES REDACTED].
Observation on 8/9/18 at 5:50 A.M., showed the following:
-The resident lay in his/her bed;
-CNA M and CNA K entered the room, prepared to perform perineal care and unfastened the
resident’s urine soiled incontinent brief;
-CNA M performed perineal care to the frontal perineal area and the left hip/buttock areas
but did not cleanse the resident’s right hip/buttock areas.
During interview on 8/9/18 at 6:25 P.M., CNA M said that all soiled areas of the
incontinent resident’s skin should be cleansed.
During interview on 8/14/18 at 6:50 P.M. the DON said the following:
-Staff should provide resident incontinence care from front to back;
-All soiled areas of an incontinent resident should be cleaned which would include thighs,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY 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 – Some

(continued… from page 7)
perineal areas, pelvis, buttocks and hips;
-He/she would expect oral care to be offered in the morning and anytime it was needed;
-Staff should assist residents every morning before breakfast with toileting, incontinence
care, oral care, and wash the resident’s face and hands.

F 0684

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure one
resident (Resident #52) in a review of 16 sampled residents received care and services in
accordance with the resident’s goals for care and professional standards of practice to
meet the resident’s physical, mental and psychosocial needs. Facility staff failed to
administer Resident #52’s medication as physician ordered, failed to obtain weekly and
daily weights as physician ordered and failed to notify the physician of the resident’s
change in condition resulting in the resident’s re-hospitalization and increased pain. The
facility census was 57.
1. Review of the facility policy Notification of Changes dated (YEAR) showed the
following:
-It was the policy of the facility that changes in a resident’s condition or treatment
were immediately reported to the attending physician or delegate. Nurses and other care
staff were educated to identify changes in a resident’s status and define changes that
require notification of the resident’s physician to ensure best outcomes of care for the
resident;
-The objective was to ensure the facility staff made appropriate notification to the
physician when there was a change in the resident’s condition that might require physician
intervention. The intent was to provide appropriate and timely information about changes
relevant to a resident’s condition to the parties who would make decisions about care,
treatment and preferences to address the changes;
-Requirements for notification of resident’s physician included a significant change in
the resident’s physical, mental, or psychosocial status such as deterioration in health,
mental or psychosocial status in either life-threatening conditions or clinical
complications and/or a need to alter treatment significantly;
-Notification was provided to the physician to facilitate continuity of care and obtain
input from the physician about changes, additions to or discontinuation of treatments
-The nurse would immediately notify the resident’s physician regarding the significant
change in condition or a need to alter treatment significantly;
-The nurse would notify the resident’s physician for non-immediate changes of condition on
the shift the change occurred unless otherwise directed by the physician and document the
notification and record any new orders in the medical record.
2. Review of the facility policy Weight Monitoring dated (MONTH) 2006 showed the
following:
-Weight and height would be obtained on each resident by the nursing department on
admission;
-Monthly weights would be completed by the nursing department by the seventh of each
month;
-Weekly weights would be obtained on residents who show a significant weight change.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 8)
3. Review of Resident #52’s face sheet showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s Physician Order Sheet (POS) dated 4/26/18 showed the following:
-[MEDICATION NAME] (diuretic medication used to remove excess fluid from the body) 20
milligrams (mg) one by mouth as needed for [MEDICAL CONDITION] (swelling of the tissues);
-Weekly weights on Thursdays;
-Supplemental oxygen at 2 liters per nasal cannula (through the nose), maintain oxygen
saturation (oxygen levels in the blood) above 90 percent (normal 92 to 100 percent).
Review of the resident’s Baseline Care Plan dated 4/26/18 showed the following:
-Disease management concerns included respiratory and pain;
-Observation detail list included oxygen therapy;
-Monitor medications, condition and report changes to Director of Nursing (DON) and
physician as applicable;
-Monitor lab values and report to physician;
-Intervention of weigh weekly not marked.
Review of the resident’s Admission Clinical assessment dated [DATE] showed the following:
-Admission weight 231 pounds;
-1+ [MEDICAL CONDITION] (the degree of observable swelling of body tissues due to fluid
accumulation that may be demonstrated by applying pressure to the swollen area such as by
depressing the skin with a finger. Ranges from 1+ up 4+) to both feet;
-Regular and unlabored breathing and right and left upper lung fields clear. Right and
left lower lung fields diminished.
Review of the resident’s Admission Minimum Data Set (MDS) a federally mandated assessment
instrument, completed by facility staff, dated 5/3/18 showed the following:
-Moderately impaired cognition;
-Required extensive assistance of two staff members with bed mobility, dressing and
toileting;
-Required total assistance of two staff members with transfers;
-Received scheduled and as needed pain medication in the last five days;
-Frequent presence of pain in the last five days that effected the resident’s sleep and
day to day activities rated at 8 on a 0-10 pain scale;
-Shortness of breath or trouble breathing when lying flat;
-Weight 231 pounds;
-Received no diuretic medication in the previous seven days.
Review of the resident’s POS dated (MONTH) (YEAR) showed weekly weights on Thursday
related to [MEDICAL CONDITION] (a heart condition of the inability or failure of the heart
to adequately meet the needs of organs and tissues for oxygen and nutrients causing fluid
to leak from capillary blood vessels into the tissues. This leads to symptoms that may
include shortness of breath, weakness, and swelling of tissues and fluid in the lungs).
Review of the resident’s nurses’ notes showed the following:
-On 5/3/18 lung sounds diminished in lower lobes bilaterally;
-On 5/5/18 lung sounds diminished;
-On 5/8/18 lung sounds diminished throughout.
Review of the resident’s MAR indicated [REDACTED].
Review of the resident’s Treatment Administration Record (TAR) dated (MONTH) (YEAR) showed
the following:
-On 5/10/18 weight 228.6;
-Staff documented no other weights for the month of May.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 9)
Review of the resident’s nurses’ notes showed the following:
-On 5/13/18 choked on bedtime medication, complained of extreme shortness of breath,
oxygen saturation 42 percent on 4 liters of supplemental oxygen. Oxygen changed from nasal
cannula to mask with oxygen saturation increased to 73 percent. The physician was notified
and resident was transferred to the emergency room by ambulance;
-On 5/14/18 resident admitted to the hospital with [REDACTED].
Review of the resident’s POS dated 6/4/18 showed the following:
-Readmit to facility;
-[DIAGNOSES REDACTED].
-Weekly weights;
-[MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL
CONDITION].
Review of the resident’s TAR showed on 6/7/18 a weight of 202.6 pounds.
Review of the resident’s MAR indicated [REDACTED].
Review of the nurses’ note dated 6/10/18 showed the resident was on [MEDICATION NAME] for
2+ [MEDICAL CONDITION] of bilateral (both) lower extremities (The MAR indicated
[REDACTED]. Lungs clear with respirations unlabored. Becomes short of air easily.
Review of the resident’s Admission MDS dated [DATE] showed the following:
-Severely impaired cognition;
-Required total assistance of two staff members with bed mobility, dressing, toileting and
transfers;
-Received as needed pain medication in the last five days;
-Frequent presence of pain in the last five days that effected the resident’s sleep and
day to day activities rated at eight on a 0-10 pain scale;
-Shortness of breath or trouble breathing when lying flat;
-Weight 207 pounds;
-Received no diuretic medication in the previous seven days.
Review of the nurses’ note dated 6/14/18 showed the resident’s lungs were clear,
respirations labored at times with exertion.
Review of the resident’s care plan dated 6/15/18 showed the following:
-The resident was at risk for pneumonia (lung infection), upper respiratory infection and
respiratory distress related to [DIAGNOSES REDACTED]. Staff should administer medications
as ordered, monitor supplemental oxygen use at 2 liters per nasal cannula, monitor for
peripheral (arms and legs) [MEDICAL CONDITION] and notify physician of increased [MEDICAL
CONDITION], monitor weights as ordered and document, monitor for lung congestion,
shortness of breath and notify the physician of changes;
-The resident had [MEDICAL CONDITION] and was at risk for complications. Staff should
monitor for pain and administer pain medications as ordered;
-The resident had intermittent complaints of pain. Staff should monitor for signs and
symptoms of discomfort, notify the medication nurse of pain and administer pain
medications as ordered. Staff should notify the physician if interventions were
unsuccessful of if current complaint was a significant change in past experience of pain;
-The resident was at risk for cardiac complications. Staff should monitor for increased
[MEDICAL CONDITION] and administer [MEDICATION NAME] as ordered, if unresolved notify
physician. Staff should monitor weights and vital signs as ordered and notify physician of
changes in cognition.
Review of the resident’s TAR for (MONTH) (YEAR) showed the following:
-Staff documented no assessment of the resident’s weight on 6/11/18 (Physician ordered
weekly weights beginning 6/4/18);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 10)
-On 6/18/18 weight of 209.6 pounds, a seven pound weight gain in 11 days;
Review of the resident’s nurses’ notes dated 6/18/18 showed no documentation staff
notified the resident’s physician of the seven pound weight gain in 11 days.
Review of the resident’s nurses’ notes showed on 6/25/18 staff documented the resident was
sliding out of his/her wheelchair and unable to go to his/her physician’s appointment.
Lung sounds diminished, respirations labored with any exertion, abdomen firm.
Review of the resident’s Electronic Medical Record (EMR) showed on 6/25/18 staff
documented the resident’s blood pressure was 141/92 millimeters of mercury (mmHg)(normal
120/80). No documentation staff notified the physician of resident’s condition.
Review of the resident’s nurses’ notes showed on 6/26/18 staff documented the resident’s
lung sounds with expiratory wheezes and diminished breath sounds in posterior bases. Will
continue with current plan of care.
Review of the resident’s EMR showed on 6/25/18 staff documented the resident’s blood
pressure was 89/77 with no documentation staff notified the physician of the resident’s
condition.
Review of the resident’s nurses’ notes showed on 6/27/18 staff documented the resident’s
lungs with faint wheezes in bilateral upper lung fields with no documentation staff
notified the resident’s physician.
Review of the resident’s computed tomography scan (CT scan) (x-ray measurements taken from
different angles to produce cross-sectional images of specific areas of the body) scan of
the abdomen and pelvis (related to a groin wound) dated 6/29/18 showed a small right
effusion and trace left effusion with bibasilar (both lung bases) subsequent atelectasis
(collapsing of part of the lung).
Review of the resident’s MAR indicated [REDACTED].
Review of the resident’s electronic medical record vital signs tab dated 7/1/18 showed the
resident’s weight as 219.2 pounds, a 10 pound weight gain from the previous weight on
6/18/18 and a 16 pound weight gain from his/her readmission weight on 6/4/18.
Review of the resident’s MAR indicated [REDACTED].
Review of the resident’s nurses’ notes showed staff documented on 7/1/18 the resident’s
lungs were clear, abdomen slightly distended, no [MEDICAL CONDITION] noted. The resident
preferred not to get out of bed. Periods of confusion noted.
Review of the resident’s EMR vital signs tab showed staff documented the following:
-On 7/1/18 the resident’s blood pressure was 138/52 mmHg and respirations 22 breaths per
minute (normal 12-20 breaths per minute);
-On 7/2/18 the resident’s blood pressure was 167/77 mmHg.
Review of the resident’s nurses’ notes showed staff documented the following:
-On 7/3/18 the resident had light wheezes in the upper bilateral lung fields;
-On 7/4/18 the resident refused repositioning during the night.
Review of the resident’s EMR vital signs tab dated 7/4/18 showed staff documented the
resident’s blood pressure was 173/89 mmHg.
Review of the resident’s nurses’ notes showed staff documented the following:
-On 7/5/18 the resident refused turning side to side, preferred to lay on back at all
times;
-On 7/6/18 the resident complained of pain at times to feet and back, had a poor appetite,
was total assistance with activities of daily living, lungs were clear.
Review of a Registered Dietician note dated 7/6/18 showed the resident’s weight was up 16
pounds over the last 30 days.
Review of the resident’s MAR indicated [REDACTED].
Review of the resident’s nurses’ notes dated 7/10/18 showed the resident’s skin was moist
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 11)
and [MEDICAL CONDITION] from left thigh to foot, from abdomen around to back with bottom
part of back hard to touch, and had a weight gain of nine pounds in two days with lung
sounds diminished on the right and crackles to the left posterior lung fields. The
resident complained of back and abdominal pain. The physician was notified and orders
received to send the resident to the emergency room for evaluation. Resident transferred
by ambulance.
Review of the resident’s hospital transfer form dated 7/10/18 showed the reason for
transfer was [MEDICAL CONDITION] and crackles. He/she had low back pain, was on
supplemental oxygen at 4 liter/minute by nasal cannula.
Review of the resident’s Hospital emergency room record dated 7/10/18 showed the
following:
-Presented with complaint of leg swelling;
-History of [MEDICAL CONDITION];
-On 6/29/18 the resident had a CT of his abdomen and pelvis to evaluate a cutaneous groin
abscess. This found [MEDICAL CONDITION] (liver disease) with small volume of ascites
(fluid accumulation in the abdominal cavity) in abdomen and pelvis;
-Presented with increased abdominal ascites going on for the past five days, increased
weight gain from 219 pounds to 228 pounds, crackles in left lung base. Chronically on
oxygen at 3 liters by nasal cannula;
-Chest x ray showed trace pleural effusions (pleural space or sac around the lung
contained fluid) and chronically enlarged cardiac silhouette (enlarged heart);
-Medications administered in the emergency department included [MEDICATION NAME] 40 mg
intravenous (IV) and [MEDICATION NAME] (narcotic pain medication) 4 mg;
-Clinical impression was anasarca (wide spread swelling of the skin due to effusion or
spreading of fluid into the extracellular space), [MEDICAL CONDITION] (high potassium
blood level), [MEDICAL CONDITION] and acute on chronic [MEDICAL CONDITION].
Review of the resident’s Hospital Inpatient Discharge Summary dated 7/16/18 showed the
following:
-Discharge [DIAGNOSES REDACTED]. The heart has to work harder to pump the blood), acute
kidney injury superimposed on [MEDICAL CONDITION] and [MEDICAL CONDITION] stage five;
-Hospital course: admitted for increasing weight gain following discharge to nursing
facility. Was found to have acute on chronic diastolic [MEDICAL CONDITION] due to
inadequate diuresis (the process of removal of excess fluid from the tissues with
medication). The resident was [MEDICATION NAME] with improvement in ascara. Nephrology
(kidney specialist) was consulted and resident was placed on [MEDICATION NAME] (diuretic
medication used to remove excess fluid from the tissues) 50 mg by mouth daily. Educated
extensively regarding monitoring daily weights and titrate diuretics based on fluid
status. discharged to skilled nursing facility with new prescription of [MEDICATION NAME];
-Special instructions: Resident started on [MEDICATION NAME] 50 mg daily for diastolic
[MEDICAL CONDITION] in the setting of [MEDICAL CONDITION] stage 3. Weight/fluid status as
well as electrolytes and renal function (blood tests) should be monitored and [MEDICATION
NAME] dose titrated as appropriate. Recommend repeat Basic Metabolic Panel (BMP)
(laboratory blood test) in 2-3 days;
-Discharge medications included [MEDICATION NAME] 50 mg daily.
Review of the resident’s Post-Acute Care Transport Report from the hospital to the
facility dated 7/16/18 showed the following:
-Weight 213 pounds 10 ounces;
-Medication orders included [MEDICATION NAME] 50 mg daily with instructions resident was
started on [MEDICATION NAME] 50 mg daily for diastolic [MEDICAL CONDITION] in the setting
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 12)
of [MEDICAL CONDITION] stage three. Weight/fluid status as well as electrolytes and renal
function should be monitored and [MEDICATION NAME] dose titrated as appropriate. Recommend
repeat BMP in two to three days.
Review of the resident’s POS showed the following:
-On 7/16/18 readmit to facility with previous orders. Add [MEDICATION NAME] 10 mg daily
(40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge
physician);
-On 7/17/18 daily weights for two weeks.
Review of the resident’s MAR indicated [REDACTED]
-No administration of [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION]
related to [MEDICAL CONDITION];
-No administration of [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital
discharge.
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician) one time daily (MONTH) 17 through
(MONTH) 28.
Review of the resident’s nurses’ note dated 7/16/18 showed readmit from the hospital,
physician notified of readmission and new orders. Lungs clear.
Review of the resident’s TAR dated /18 and 7/18/18 showed no documentation staff obtained
daily weights.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE]
hospital discharge.
Review of the resident’s nurses’ note dated 7/18/18 showed lungs with expiratory wheezing
in lower bases.
Review of the resident’s nurses’ note dated 7/19/18 showed [MEDICAL CONDITION] to lower
extremities 2+.
Review of the resident’s TAR on 7/19/18 showed staff obtained no ordered daily weight.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the
7/16/18 hospital discharge.
Review of the resident’s TAR on 7/20/18 showed no documentation staff obtained the
resident’s daily weight.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the
7/16/18 hospital discharge.
Review of the resident’s nurses’ note dated 7/21/18 showed staff documented the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 13)
lungs were clear, respirations labored with exertion.
Review of the resident’s TAR on 7/21/18 and 7/22/18 showed no documentation staff obtained
the resident’s daily weight.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE]
hospital discharge.
Review of the resident’s TAR showed the following:
-On 7/23/18 weight 228.8 pounds. A 15 pound weight gain since 7/16/18;
-On 7/24/18 no daily weight obtained.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the
7/16/18 hospital discharge.
Review of the resident’s EMR showed staff documented the following:
-On 7/23/18 blood pressure 134/83 mmHg;
-On 7/24/18 blood pressure 181/87 mmHg.
Review of the resident’s nurses’ notes showed staff documented the following:
-On 7/25/18 lungs diminished in bases;
-On 7/26/18 lungs diminished, respirations labored with exertion, abdomen distended.
Review of the resident’s EMR dated 7/26/18 showed staff documented the the resident’s
blood pressure was 135/97 mmHg.
Review of the resident’s TAR on 7/25/18 and 7/26/18 showed no documentation staff obtained
the resident’s daily weights.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE]
hospital discharge.
Review of the resident’s TAR showed on 7/27/18 a weight of 232.6 pounds, a 19 pound weight
gain since 7/16/18.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of
[MEDICATION NAME] by the hospital discharge physician);
-No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE]
hospital discharge.
Review of the resident’s POS dated 7/27/18 showed a new order for [MEDICATION NAME] 10 mg
as needed (PRN) for a weight gain of 3 pounds or increased [MEDICAL CONDITION] in addition
to the current [MEDICATION NAME] dose. (facility was still giving 10 mg. of [MEDICATION
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 14)
NAME] rather than the ordered 50 mg.; this day the resident received a total of 20 mg.
[MEDICATION NAME]).
Review of the resident’s MAR indicated [REDACTED].M. staff administered an additional
[MEDICATION NAME] 10 mg as needed for a weight gain of 3 pounds or increased [MEDICAL
CONDITION]. (Total of [MEDICATION NAME] 20mg administered on 7/27/18, 30mg less than the
prescribed dose of [MEDICATION NAME] by the hospital discharge physician).
Review of the resident’s EMR dated 7/28/18 showed staff documented the resident’s blood
pressure was 149/98mmHg.
Review of the resident’s nurses’ note dated 7/28/18 showed staff documented the following:
-Total dependence on staff with activities of daily living;
-Staff turned and repositioned resident. He/she refused to sit up in wheelchair;
-Daily weights.
Review of the resident’s TAR showed on 7/28/18 a weight of 231.0 pounds; an 18 pound
weight gain since 7/16/18.
Review of the resident’s MAR indicated [REDACTED]
-No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL
CONDITION] related to [MEDICAL CONDITION];
-[MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME]
by the hospital discharge physician) administered;
-No administration of [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital
discharge.
Review of the resident’s nurses’ note dated 7/29/18 showed on 7/28/18 the resident was
transferred to the hospital via ambulance at 9:00 P.M. Staff noted thick yellow-white
urine with thick sediment in urinary catheter. Noted increased abdominal girth, puffy
[MEDICAL CONDITION] to bilateral upper extremities, fluid pockets to back of head and
neck, [MEDICAL CONDITION] present to face and [MEDICAL CONDITION] to temple.
Review of the resident’s hospital transfer form dated 7/28/18 showed reason for transfer
was fluid overload, B/P 188/78, pain level 10/10 with pain medication administered at 8:30
P.M.
Review of the resident’s Hospital emergency room record dated 7/28/18 showed the
following:
-Chief compliant of leg swelling, leg, abdomen and facial fluid retention, shortness of
breath;
-History of [MEDICAL CONDITION] chronically on supplemental oxygen at 3 liters per nasal
cannula. Presented to the emergency department with shortness of breath onset yesterday
and worsening today as well as extremity [MEDICAL CONDITION] and 8-9 pound weight gain
over the last few days (219 pounds on 7/1/18 and 232 pounds today). Recent urinary
catheter placed. Past medical history included hosptalized on [DATE] for anasarca;
-Respiratory status was shortness of breath with decreased breath sounds in the right
lower field;
-[MEDICAL CONDITION] with 3+ pitting from feet to groin bilaterally. Swelling of arms and
legs;
-Abdominal distension and ascites;
-Lab results of B-type Natriuretic Peptide (Pro BNP) ( substances that are produced in the
heart and released when the heart is stretched and working hard to pump blood. Tests for
BNP and NT-proBNP measure the levels in the blood in order to detect and evaluate heart
failure with levels above 1200 picogram/ml in a person with kidney disease indicating
[MEDICAL CONDITION]). Results of 6,551 pg/ml;
-Clinical impression of urinary tract infection associated with indwelling urinary
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 15)
catheter, acute [MEDICAL CONDITION] superimposed on [MEDICAL CONDITION], chronic [MEDICAL
CONDITION].
Review of the resident’s Hospital History and Physical dated 7/29/18 showed the resident
was last seen at the hospital on [DATE] under admission and underwent treatment with
diuresis for decompensated heart failure, was transitioned to by mouth diuretics and
discharged to skilled nursing facility.
Review of the resident’s Hospital Inpatient Discharge Summary dated 8/9/18 showed the
following:
-[DIAGNOSES REDACTED].
-Resident was discharged from the hospital on [DATE] after treatment of [REDACTED].
-Known diastolic [MEDICAL CONDITION], inadvertently following the last discharge the
resident only received 10 mg of [MEDICATION NAME] daily instead of 50 mg of [MEDICATION
NAME] daily that was prescribed at the time of discharge and this was likely cause for
acute heart failure exacerbation;
-On 8/9/18 resident was seen by palliative care and based on 24 hour [MEDICATION NAME]
utilization start [MEDICATION NAME] (a long acting narcotic pain medication absorbed
through the skin through placement of a patch) 12 microgram (mcg) patch with [MEDICATION
NAME] ([MEDICATION NAME] with [MEDICATION NAME] narcotic pain medication) one tablet every
four hours as needed for breakthrough pain. Discharge prescriptions provided for facility;
-Acute on [MEDICAL CONDITION] stage 3 or 4 likely secondary [MEDICAL CONDITION] as well as
acute on chronic diastolic [MEDICAL CONDITION];
-Firm [MEDICAL CONDITION] over bilateral lower abdomen, hips, upper thighs, legs and feet
at discharge.
Review of the nurses’ note showed on 8/9/18 the resident was admitted to facility.
Review of the resident’s POS dated 8/9/18 showed the following:
-[MEDICATION NAME] 50 mg daily;
-Daily weights;
-[MEDICATION NAME] 12 mcg/hour patch, change every third day, placed on 8/9/18, change
8/12/18;
-[MEDICATION NAME] 5/325 mg one or two tablets every four hours as needed for pain.
Observations of the resident on 8/9/18 at 10:30 A.M. showed the following:
-[MEDICAL CONDITION] noted to bilateral feet and legs, arms and hands appear fluid filled
and puffy;
-Attempted to answer questions and talk with family with repetitive answers and difficulty
understanding questions and topic of conversation.
During interview on 8/9/18 at 3:00 P.M. the resident’s family said the following:
-Staff did not administer the resident’s [MEDICATION NAME] dose correctly. Staff gave
[MEDICATION NAME] 10mg daily instead of 50mg daily and the resident filled up with fluid.
His/her hands, arms, feet and legs were full of fluid and had areas of fluid weeping out
the skin. He/she was transferred to the hospital in respiratory distress;
-Staff delayed his/her treatment for [REDACTED].
-The family informed the staff three times the resident needed to go to the hospital
before the ambulance was called.
Review of the resident’s MAR indicated [REDACTED].M. staff administered [MEDICATION NAME]
5/325 mg one tablet.
Review of the nurses’ note showed on 8/10/18 staff documented the resident was on comfort
measures.
Review of the resident’s MAR indicated [REDACTED]
-On the 6:00 A.M. to 2:00 P.M. shift the resident’s pain level was zero on a scale of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 16)
1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet;
-On the 2:00 P.M. to 10:00 P.M. shift the resident’s pain level was zero on a scale of
1-10. At 7:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet;
-On the 10:00 P.M. to 6:00 A.M. shift the resident’s pain level was zero on a scale of
1-10.
Review of the nurses’ notes dated 8/11/18 showed the resident’s lungs were diminished
throughout, abdomen round and firm. Physician notified and ordered comfort medications
sublingual only. Discussed with family resident’s current status including multiple organs
failing and wish to be comfortable. Several new comfort medication orders received,
resident concerned about pain.
Review of the resident’s MAR indicated [REDACTED]
-On the 6:00 A.M. to 2:00 P.M. shift the resident’s pain level was four on a scale of
1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the
resident said he/she felt bad all over;
-On the 2:00 P.M. to 10:00 P.M. shift the resident’s pain level was five on a scale of
1-10. At 2:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the
resident hurt;
-On the 10:00 P.M. to 6:00 A.M. shift the resident’s pain level was eight on a scale of
1-10. No documentation of pain medication administered.
Review of the nurses’ note dated 8/12/18 showed the resident was concerned about pain.
His/her abdomen was distended and tight with absent bowel sounds. Lungs were diminished
with bilateral peri

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary treatment and services consistent with standards of practice to promote healing
of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear and /or
friction) for two residents of 16 sampled residents (Residents #49 and #110), who the
facility identified at risk of developing new pressure ulcers and who had existing
pressure ulcers. Staff failed to provide wound cleansing, treatment and apply a dressing
following a shower for over 12 hours for Resident #49 and failed to address the pressure
ulcer on the care plan and apply the ordered dressing for four days for Resident #110 .
The facility census was 57.
1. Review of the RAI User’s Manual (Long-term Care Facility Resident Assessment Instrument
User’s Manual) Chapter 3, Section M, defines the different stages of pressure ulcers
(localized injury to the skin and/or underlying tissue usually over a bony prominence, as
a result of pressure, or pressure in combination with shear and/or friction) as follows:
-Stage I: an observable, pressure related alteration of intact skin, whose indicators as
compared to an adjacent or opposite area on the body may include changes in skin
temperature, tissue consistency, sensation, and/or a defined area of persistent redness;
-Stage II: Partial thickness loss of dermis (the inner layer that makes up skin)
presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable
yellow, tan, gray, green or brown tissue). (MONTH) also present as an intact or
open/ruptured blister;
-Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265407

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

MOBERLY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

700 EAST URBANDALE DRIVE
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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
or muscle is not exposed. Slough may be present but does not obscure the depth of tissue
loss. (MONTH) include undermining (destruction of tissue or ulceration extending under the
skin edges) or tunneling (a passage way of tissue destruction under the skin surface that
has an opening at the skin level from the edge of the wound).
2. Review of the facility policy Pressure Ulcer, Care and Prevention of, Nursing
Guidelines Manual, (MONTH) (YEAR) showed the following:
-Purpose was to prevent and treat further breakdown of pressure sores;
-treatment of [REDACTED]. The nurse was responsible for carrying out the treatment as
ordered by the physician and for implementing measures to prevent pressure ulcers.
3. Review of the facility policy General Wound and Skin Care Guidelines, MedSupply (YEAR)
showed the following:
-Wash hands before and after resident contact;
-All chronic wounds were contaminated. Chronic wounds should be dressed using a clean
technique;
-Reevaluate dressing and skin integrity every shift;
-Use care when removing dressings and tapes to avoid further damage to fr