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 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

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 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 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 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 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 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 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 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 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 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 – 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 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 – 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 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 – 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 TAG SUMMARY 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 fragile skin;
-Notify appropriate personnel of all new pressure ulcers, or if have questions;
-Educate residents, families, and staff on interventions to prevent skin breakdown.
4. Review of Resident #49’s Braden Scale (scale for predicting pressure ulcer risk) dated
1/4/18 showed the following:
-[DIAGNOSES REDACTED].
-Sensory perception was very limited responds only to painful stimuli (score 2);
-Occasionally moist skin, required an extra linen change approximately once per day (score
3);
-Chairfast, could not bear weight and /or must be assisted into chair or wheelchair (score
2);
-Mobility very limited unable to make frequent or significant changes independently (score
2);
-Nutrition probably inadequate, rarely ate a complete meal and generally ate only about
1/2 of food offered (score 2);
-Friction and shear problem, required moderate to maximum assist in moving, complete
lifting without sliding against sheets was impossible, frequently slide down in bed or
chair, required frequent repositioning with maximum assist (score 1);
-Total Braden Scale Score was 12. Level as HIGH RISK (range 10-12).
Review of the resident’s significant change Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 4/30/18 showed the following:
-[DIAGNOSES REDACTED].
-Cognitively intact;
-Required total assistance of two staff members with transfers;
-Required extensive assistance of two staff members with bed mobility and dressing;
-Required extensive assistance of one staff member with toileting;
-Required an indwelling urinary catheter and an ostomy;
-Risk of developing pressure ulcers;
-One or more unhealed pressure ulcers at stage 1 or higher;
-One stage 3 pressure ulcer present on admission measured 4.5 centimeters (cm) long by
2.5cm wide and 0.2cm deep;
-One stage 3 pressure ulcer worsening in status;
-Pressure reducing device (equipment that aims to relieve pressure away from areas of high
risk for skin breakdown) for chair and bed, turning and repositioning program, pressure
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 TAG SUMMARY 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 18)
ulcer care and application of ointments and medications.
Review of the resident’s wound management physician note dated 5/31/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 5.0 cm long by 5.0 cm wide and 0.2 cm deep
with large amount of blood tinged drainage. Facility staff should change the resident’s
dressing twice daily and as needed for soiling;
-Trauma left ischial (part of the pelvic bone located at the lower buttocks, the sitting
bone) wound measured 1.0 cm long by 2.0 cm wide and 1.5 cm deep with moderate amount of
pink tinged drainage. Facility staff should change the resident’s dressing daily and as
needed for soiling. Excisional debridement of wound performed;
-Considering re-culturing (laboratory test of the wound tissue and drainage for infection)
the wound next week if things were not different.
Review of the Physician’s Order Sheet (POS) dated 5/31/18 showed the following:
-Left buttock pressure ulcer cleanse with wound cleanser, apply Sure Prep on surrounding
tissue, apply bio-pad (wound treatment dressing used to control minor bleeding and for
management of chronic non-healing wounds) to wound bed, cover with alginate (wound
dressing used to maintain a moist microenvironment that promotes healing) and border gauze
(absorptive gauze dressing with taped edges placed on top of a wound), change twice daily
and as needed for soiling or dislodgement;
-Left ischium wound cleanse with wound cleanser, apply sure prep on surrounding tissue,
apply bio-pad to wound bed, cover with alginate and border gauze, change daily and as
needed for soiling or dislodgement.
Review of the POS [REDACTED]
-Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding
tissue, apply alginate to wound bed and cover with border gauze, change daily and as
needed for soiling or dislodgement
-Left ischium wound cleanse with wound cleanser, apply Sure Prep on surrounding tissue,
apply sure prep on surrounding tissue, pack wound with alginate, cover with border gauze
and change daily and as needed for soiling or dislodgement.
Review of the resident’s wound management physician note dated 6/7/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 5.0 cm long by 5.0 cm wide and 0.2 cm deep
with evidence of pressure noted, moderate amount of blood tinged drainage. Facility staff
should change the resident’s dressing daily and as needed for soiling;
-Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep with
moderate amount of pink tinged drainage. Facility staff should change the resident’s
dressing daily and as needed for soiling.
Review of the resident’s wound management physician note dated 6/21/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 4.0 cm long by 5.0 cm wide and 0.2 cm deep
deteriorated wound status, moderate amount of blood tinged drainage. Facility staff should
change the resident’s dressing daily and as needed for soiling;
-Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep moderate
amount of pink tinged drainage. Facility staff should change the resident’s dressing daily
and as needed for soiling.
Review of the POS [REDACTED]
-Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding
tissue, apply bio-pad to wound bed, cover with alginate and border gauze, change daily and
as needed for soiling or dislodgement;
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 TAG SUMMARY 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 19)
-Left ischium wound cleanse with wound cleanser, apply sure Prep on surrounding tissue,
apply Sure Prep on surrounding tissue, apply bio-pad to wound bed, cover with alginate and
border gauze, change daily and as needed for soiling or dislodgement.
Review of the resident’s wound management physician note dated 6/28/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 3.5 cm long by 4.5 cm wide and 0.2 cm deep,
moderate amount of blood tinged drainage. Facility staff should change the resident’s
dressing daily and as needed for soiling;
-Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep moderate
amount of pink tinged drainage. Facility staff should change the resident’s dressing daily
and as needed for soiling;
-Considering re-culture of wounds.
Review of the resident’s wound management physician note dated 7/5/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 4.0 cm long by 4.0 cm wide and 0.2 cm deep
with deteriorated wound status not healthy appearance, moderate amount of blood tinged
drainage. Facility staff should change the resident’s dressing daily and as needed for
soiling;
-Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep with pink
granulating tissue, moderate amount of pink tinged drainage. Facility staff should change
the resident’s dressing daily and as needed for soiling;
-Tissue culture and sensitivity sent to laboratory.
Review of the resident’s POS showed continue the same wound treatment procedure, increase
frequency to twice daily.
Review of the resident’s care plan dated 7/19/18 showed the following:
-The resident had a stage 3 pressure ulcer on the left buttock and a previous trauma wound
that reopened on the left ischium. Staff should turn and reposition the resident every two
hours to prevent skin breakdown and utilize wedges and pillows to reduce pressure and
provide assistance with all Activities of Daily Living (ADLs), bed mobility, toileting and
transfers. Staff should cleanse the stage 3 pressure ulcer of the left buttock with
cleanser and physician ordered treatment daily and as needed for soiling or dislodgement.
Staff should cleanse the left ischial wound with cleanser and physician ordered treatment
daily and as needed for soiling or dislodgement. Staff should monitor for signs and
symptoms of non-healing and infection (increased redness, warmth or tenderness, foul
smelling or purulent drainage, fever) and notify the physician. Staff should monitor skin
for further redness and breakdown, if noted notify the charge nurse. If a decline in skin
condition was noted, notify physician and request treatment orders;
-The resident was weak with limited range of motion and [DIAGNOSES REDACTED] in legs and
was unable to straighten out legs. Required extensive assistance on one or two staff
members with all ADLs. Staff should shower the resident twice weekly, provide mechanical
lift transfers, and assist with re-positioning every two hours while in bed or out of bed
in wheelchair;
-The resident had a [MEDICAL CONDITION]. Staff should change the appliance every three
days and as needed. Monitor the output and record, observe for leakage and change as
needed;
-The resident had a suprapubic urinary catheter (sterile tube inserted through the lower
abdominal wall into the bladder use to drain the bladder of urine). Staff should monitor
placement of the urinary catheter and maintain a closed drainage system.
Review of the resident’s wound management physician note dated 7/26/18 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 TAG SUMMARY 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 20)
following:
-Stage 3 left buttock pressure ulcer measured 3.5 cm long by 2.0 cm wide and 0.2 cm deep
with deteriorated wound status, small amount of blood tinged drainage. There was an
infection in the wound. Facility staff should change the resident’s dressing daily and as
needed for soiling;
-Trauma left ischial wound measured 1.0 cm long by 2.0 cm wide and 2.0 cm deep, small
amount of pink tinged drainage. There was an infection in the wound. Facility staff should
change the resident’s dressing daily and as needed for soiling;
-Wound cultures showed Escherichia coli (bacteria normally present in the intestines,
frequent cause of urinary tract and wound infections) and Proteus (bacteria present in the
intestines, water and soil), start Bactrim DS (antibiotic medication) twice daily.
Review of the POS [REDACTED]
-Bactrim DS one tablet twice daily for 14 days;
-Left buttock pressure ulcer cleanse with wound cleanser, apply sure prep on surrounding
tissue, mix hydrogel (wound treatment gel designed to keep the wound slightly moist) and
collagen, place in wound bed and cover with border gauze, change daily and as needed for
soiling or dislodgement
-Left ischium wound cleanse with wound cleanser, apply sure prep on surrounding tissue,
mix hydrogel and collagen, place in wound bed and cover with border gauze, change daily
and as needed for soiling or dislodgement.
Review of the resident’s wound management physician note dated 8/6/18 showed the
following:
-Stage 3 left buttock pressure ulcer measured 2.2 cm long by 2.0 cm wide and .02 cm deep,
small amount of blood tinged drainage. Facility staff should change the resident’s
dressing daily and as needed for soiling;
-Trauma left ischial wound measured 0.5 cm long by 0.3 cm wide and 1.7 cm deep with pink
granulating tissue, small amount of blood tinged drainage. Facility staff should change
the resident’s dressing daily and as needed for soiling;
-Education provided to facility staff regarding proper wound treatment, frequent
repositioning, offloading and proper nutrition to support effective wound healing.
Observation on 8/8/18 at 9:50 A.M. showed the following:
-Licensed Practical Nurse (LPN) C prepared dressing change supplies on the resident’s
bedside table;
-The resident lay on his/her left side with buttocks exposed. A tan colored thick
substance covered the resident’s left ischial wound area with no dressing in place;
-The resident said he/she took a shower last night and the CNA removed the wound dressings
prior to the shower;
-LPN C opened the resident’s skin folds and exposed an open left inner buttock wound with
no dressing. The wound was approximately half dollar size with a dark red base;
-LPN C cleansed the resident’s left ischial wound of the tan colored thick substance
revealing an approximate pea size open area with undetermined depth. LPN C cleansed the
left inner buttock wound with wound cleanser;
-LPN C applied collagen and hydrogel wound treatment to both wounds, covered with
non-adhesive dressings and secured with tape.
During interview on 8/8/18 at 3:00 P.M. LPN C said the evening staff removed the
resident’s wound dressings on 8/7/18. Staff should cover the resident’s wounds prior to
showers or leave the dressing in place. Following the shower, the charge nurse should
provide the resident’s wound treatments and cleanse the wounds.
During interview on 8/9/18 at 4:20 P.M. CNA V said the following:
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 TAG SUMMARY 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 21)
-He/she gave the resident’s shower on 8/7/18 at approximately 9:00 P.M.;
-He/she removed the resident’s wound dressings before the shower while the resident was in
bed;
-He/she wore gloves while removing the dressings but did not wash his/her hands prior to
applying gloves;
-He/she and another staff member transferred the resident to a reclining shower chair with
the mechanical lift, provided the shower and transferred the resident back to bed with the
mechanical lift;
-He/she told the charge nurse following the shower the resident’s wound needed a dressing.
During telephone interview on 8/9/18 at 7:15 P.M. LPN Y said he/she was the charge nurse
during the 8/7/18 night shift. He/she was aware the resident had showered that evening and
the resident’s wound dressings were removed before the shower. He/she attempted to provide
the resident’s wound care at approximately 3:00 A.M. on 8/8/18. The resident did not want
to wake up and allow the wound care provided. He/she passed the wound care on to the day
shift and was unable to provide the wound care on his/her shift.
During interview on 8/10/18 the MDS Coordinator said the following:
-CNA staff should cover residents’ pressure ulcers and wounds before showers and tell the
charge nurse following the shower. The charge nurse should change the resident’s wound
dressing and cleanse the wound following the shower;
-Staff should not leave a resident’s wound soiled after a shower for hours and pass the
information on to the next shift. This could cause the wound not to improve or heal.
5. 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;
-At risk for pressure ulcers.
Review of the resident’s care plan, dated 7/11/18, showed the pressure ulcer was not
addressed.
Review of the resident’s wound report, dated 8/2/16, showed the following:
-Stage/ type: pressure ulcer;
-Location: Right ischium;
-Measurements: 2 centimeter (cm) x 1.8 cm x 0.1 cm;
-Date of onset: 7/11/18;
-Acquired: in house;
-Status: deteriorating;
-Treatment: Santyl (presription medicine that removes dead tissue from wounds)/hydrogel
(gel composed of one or more polymers suspended in water) with border gauze.
Review of the resident’s POS, dated 8/1/18, showed the following:
-Left buttock: cleanse, apply Sure Prep, apply Santyl to the wound bed, cover with border
gauze. Change daily and as needed for soiling/dislodgement (original order dated 7/19/18);
-Barrier cream to affected areas as needed for preventative (original order dated
6/21/18).
Review of the resident’s Treatment Administration Record (TAR), dated 8/1/18, showed the
following:
-Right ischium wound: Cleanse with cleanser, apply sure prep to surrounding tissue, Santyl
to wound bed, hydrogel on top, cover with border gauze. Change daily and as needed for
soiling/dislodgement (original order dated 7/26/18);
-The TAR showed a handwritten notation which read Healed on 8/4/18, although the treatment
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 TAG SUMMARY 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 22)
was recorded as completed on 8/5/18;
-The order was re-written under the original directions without a date;
-The treatment was not documented as completed on 8/6/18, 8/7/18, 8/8/18 or 8/9/18.
Review of the resident’s POS, dated (MONTH) (YEAR), showed no evidence the order to treat
the pressure ulcer on the resident’s ischium was discontinued.
During interview on 8/27/18 at 10:42 A.M., the administrator said the following:
-The treatment order, dated 7/19/18, for the left buttock should have read right buttock
as that is the only skin issue the resident has had;
-The wound documentation sheet should be dated 8/2/18 instead of 8/2/16;
-A new wound team saw the resident on 8/6/18 and marked on the TAR that the resident’s
pressure ulcer as healed but must have looked at the resident’s wrong buttock as the
administrator had interviewed nursing staff and the area was not healed.
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 and performed perineal care after removing the urine
soiled incontinent brief;
-CNA M applied barrier cream over the right ischium (hip, buttock area) pressure ulcer
which did not have a dressing;
-CNA K said the wound did require a dressing at all times, however it may have become
soiled in the night and had to be removed;
-CNA M said he/she did not see a dressing that night.
Review of the resident’s wound documentation sheet for the right ischium, dated 8/9/18,
showed the following:
-Measurements : 1 centimeter (cm) x 1 cm x 0;
-Treatment: Sure Prep as needed;
-Status: Healed.
During interview on 8/10/18 at 9:05 A.M., LPN A said the following:
-He/she worked the night of 8/8/18 and was responsible for the resident’s treatment;
-The resident was supposed to have a dressing on his/her pressure ulcer at all times;
-Staff had not reported the dressing was off;
-He/she usually checked dressings to ensure they were intact and did not know why he/she
had not checked the dressing that night;
-He/she did not know who marked it as healed on 8/4/18, as it was not healed.
During interview on 8/14/18 at 6:30 P.M., the DON said the following:
-Staff should administer residents’ treatments as ordered by the physician;
-She expected wound dressings to be applied as ordered and nursing should monitor for the
placement of the dressing every shift;
-The charge nurse should remove a resident’s wound dressing prior to showers and following
the shower the charge nurse should cleanse the resident’s wound and provide the prescribed
wound treatment;
-Staff should not leave the resident’s wound dirty and uncovered following the shower
until the next day before cleansing the wound and applying the wound treatment;
-CNA staff should tell the charge nurse if a resident’s wound dressing became soiled or
dislodged and the charge nurse should change the dressing.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
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 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 – Some

(continued… from page 23)
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
incontinence care with an indwelling urinary catheter (a sterile tube inserted through the
urethra into the bladder to drain urine) consistent with acceptable standards of practice,
failed to keep the catheter bag off the floor and below the level of the bladder, and
failed to provide appropriate treatment and services to prevent urinary tract infections
(UTIs) for five residents (Resident #11, #16, #18, #19, and #110) in a review of 16
sampled residents. The facility reported eight residents with indwelling catheters. The
facility census was 57.
1. Review of the facility’s Catheter Care policy from the Nursing Guidelines Manual dated
(MONTH) (YEAR), showed in part the following:
-The purpose is to prevent infection and reduce irritation;
-Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the
insertion site to approximately four inches outward;
-Secure catheter utilizing a leg band (optional);
-Check drainage tubing and bag to ensure that the catheter is draining properly.
2. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility manual,
showed the following:
-The bladder is considered sterile, the catheter, drainage tubing, and bag are a sterile
system;
-Drainage tubing/bags must not touch the floor; always hook to unmovable part of the bed
frame or chair;
-When transferring residents from bed to chair, always move the drainage bag over to the
chair before moving the resident;
-The drainage bag should always be below the level of the bladder;
-If moved above, urine could flow back into the bladder.
3. Review of Resident #19’s quarterly MDS dated [DATE] showed the following:
-Short and long term memory problem;
-Required extensive assistance of one staff member with dressing and personal hygiene;
-Required extensive assistance of two staff members with bed mobility and toileting;
-Required total assistance of two staff members with transfers;
-Required an indwelling urinary catheter;
-Always incontinent of bowel.
Review of the resident’s care plan dated 5/31/18 showed the following:
-[DIAGNOSES REDACTED].
-The resident had a urinary catheter and was at increased risk for UTIs and complications.
Staff should monitor placement of catheter during care and transfers, keep below the level
of the bladder, place in a catheter bag to keep up off the floor and provide catheter care
every shift and as needed. Staff should maintain a closed drainage system, monitor for
signs and symptoms of UTI (dark cloudy urine, sediment in tubing, strong urine odor);
-The resident was confused, weak and required one or two staff member assistance with ADLs
and transfers. Two staff members should provide mechanical lift transfers. Staff should
provide catheter care every shift and as needed and bowel incontinence care.
Observation on 8/7/18 at 3:55 P.M. showed the following:
-CNA U and CNA V attached the mechanical lift pad under the resident to the mechanical
lift;
-CNA U removed the resident’s urinary catheter bag from the side of the bed and hung 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 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 – Some

(continued… from page 24)
urinary catheter bag on the top bar of the mechanical lift, approximately two feet above
the level of the resident’s bladder. Cloudy yellow urine flowed down the catheter tubing
to the resident’s bladder;
-CNA U applied the resident’s shoes;
-CNA V maneuvered the mechanical lift towards the resident’s wheelchair. The resident’s
urinary catheter bag remained hanging on the top bar of the mechanical lift, approximately
two feet above the level of the resident’s bladder. No urine remained in the catheter
tubing;
-CNA V lowered the resident into the wheelchair, removed the resident’s urinary catheter
drainage bag from the top bar of the mechanical lift and handed CNA U the resident’s
catheter bag;
-CNA U placed the catheter bag in a privacy bag under the resident’s wheelchair;
-Cloudy yellow urine flowed from the resident’s bladder down the catheter tubing into the
drainage bag.
Observation on 8/8/18 at 3:00 P.M. showed NA S wiped feces from the resident’s buttocks
with wet wipes, obtained a clean wet wipe and wiped the resident’s anal area, reached
between the resident’s legs from the back and wiped the perineal area and skin folds with
the same wet wipe, turned the resident and wiped the resident’s frontal pubic area and
thighs. NA S did not wash the resident’s perineal inner skin folds or provide catheter
care.
Observation on 8/9/18 at 6:50 A.M. showed the following:
-The resident lay in bed;
-CNA I washed the resident’s pubic area and one wipe down each side of the outer perineum;
-CNA I did not wash the resident’s inner skin folds or the resident’s urinary catheter;
-CNA I and NA R turned the resident side to side, wiped the resident’s buttocks and
applied a clean incontinence brief.
Review of the resident’s nurses’ notes dated 8/9/18 showed at 8:00 P.M. on 8/8/18 the
resident’s temperature was 100.1 degrees Fahrenheit (normal 98.6 degrees Fahrenheit). The
physician was notified and order received for urinalysis with culture and sensitivity.
Review of the resident’s urinalysis dated 8/9/18 showed the following:
-Color was amber (normal: clear/yellow/straw);
-Clarity was cloudy;
-Blood- small (normal: negative);
-[MEDICATION NAME]-positive;
-Leukocyte (a white blood cell in the urine indicating UTI)-large (normal: negative);
-White blood cells-too numerous to count;
-Red blood cells-5-15 (normal: 0-4);
-Bacteria-few.
During interview on 8/9/18 at 2:25 P.M. CNA U said the following:
-He/she should place a resident’s catheter bag under the resident’s wheelchair and not on
the floor;
-He/she should not hold the resident’s catheter bag above the level of the resident’s
bladder;
-He/she should provide catheter care down the tubing from the insertion site and provide
perineal care from front to back;
-He/she did not have anywhere else to hang the catheter bag during a mechanical lift
transfer except on the top bar of the lift;
-If the resident was incontinent of bowel, then he/she would do complete catheter care and
perineal care.
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 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 – Some

(continued… from page 25)
During interview on 8/9/18 at 4:20 P.M. CNA V said the following:
-He/she washed the resident’s catheter tubing with wet wipes and washed up and down the
catheter tubing from the insertion site;
-He/she washed the resident’s perineal area from back to front;
-He/she should place the resident’s urinary catheter bag below the level of the bladder.
Urine running back into the bladder could cause infection.
4. Review of Resident #18’s care plan dated 5/2/18 and last revised 8/2/18, showed the
following:
-Problem: Indwelling urinary catheter, at risk for UTIs;
-Goal: I will have no complications or UTIs related to my use of urinary catheter;
-Approaches: Monitor placement of my catheter during care and transfers, place in a
catheter bag to keep off the floor. Provide catheter care every shift and PRN.
Review of the resident’s UA dated 6/4/18 showed the following:
-Bacteria: Few (none);
-Leukocytes: large (negative).
Review of the resident’s urine culture report dated 6/6/18 showed greater than 100,000
CFU/ML E Coli (ESBL+) Currently on [MEDICATION NAME] 250 mg by mouth two times daily.
Review of the resident’s urine culture report dated 7/7/18 showed the organism was E Coli.

Review of the resident’s urine culture report dated 7/20/18 showed:
-Escherichia Coli (ESBL+);
-Notation: [MEDICATION NAME] (antibiotic) 250 mg by mouth daily.
Review of the resident’s medical record showed a new order for [MEDICATION NAME] 500mg
(two capsules) po stat (immediately) then one capsule po until gone (7/23/18).
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Indwelling catheter;
-Occasionally incontinent of bowel;
-Limited assist of one staff for bed mobility, personal hygiene, dressing and transfers.
Review of the resident’s POS dated 8/1/18 through 8/31/18 showed the following:
-[DIAGNOSES REDACTED].
-Urinary catheter care every shift and PRN;
-[MEDICATION NAME] (antibiotic) 500 mg by mouth every six hours until gone.
Observation on 8/08/18 at 2:32 PM showed the resident lay in his/her bed and the catheter
bag hung from the bed frame and touched the floor.
Observations on 8/09/18 showed the following:
-At 5:30 A.M. the resident lay in his/her bed with catheter tubing on the floor;
-At 5:54 A.M. the resident lay in his/her bed (low to floor) as the catheter tubing and
dignity bag (which contained the urinary drainage bag) touched the floor.
Observation on 8/9/18 at 6:50 AM showed the following:
-The resident lay on his/her back in the bed with the catheter tubing touching the floor;
– CNA K entered the room and prepared wash cloths. He/she removed the resident’s dry
incontinent brief and performed perineal care. He/she wiped the left groin and without
folding the cloth, wiped the right groin and then with the same cloth surface, wiped
around the catheter insertion site. (He/she did not cleanse the catheter tubing from the
insertion site);
-He/she dressed the resident, assisted him/her to the side of the bed and moved the urine
drainage bag from the bed frame to the dignity bag under the wheelchair. The tubing
remained on the floor. As CNA K finished morning cares his/her right foot stepped on the
catheter tubing;

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 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 – Some

(continued… from page 26)
-CNA K assisted the resident to the wheelchair and the resident wheeled him/herself out of
the room and down the hall as the catheter tubing drug the floor.
During interview on 8/9/18 at 11:35 A.M and 8/21/18 at 2:32 P.M. CNA K said the following:
-CNAs are responsible for catheter care and he/she did not perform it on the resident this
morning;
-No part of the urinary drainage system should touch the floor as would be an infection
control issue;
-Catheter care should be done during perineal care in the morning;
-Catheter care should include cleaning the catheter from the insertion site outward with a
clean wash cloth.
5. Review of Resident #16’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Total dependence of two staff for bed mobility and transfers;
-Supra-pubic catheter (thin sterile tube inserted through the abdominal wall directly into
the bladder to drain urine from the body);
-No history of UTI.
Review of the resident’s UA, dated 6/11/18 showed the following:
-Leukocytes: Large (negative);
-WBCs: Too numerous to count (0-4);
-Red blood cells (RBCs): 16-25 (0-4);
-Bacteria: Rare (none);
-Amorphous crystal: few (none).
Review of the resident’s Physician order [REDACTED].
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 (ADLs) and transfers;
-Approaches: Assist of two staff and Hoyer lift (mechanical lift used for non- weight
bearing residents) for transfers, notify my physician of changes or decline in condition,
monitor skin for redness or breakdown and notify charge nurse;
-Problem; Supra-pubic catheter, Increased risk for UTI’s due to indwelling catheter;
-Approaches: Monitor placement of my catheter during care and transfers, keep below the
level of the bladder, place in a catheter bag and keep up off of floor.
Review of the resident’s POS dated 8/1/18 to 8/31/18 showed the following:
-[DIAGNOSES REDACTED]. Symptoms can include retention);
-Supra-pubic catheter (6/1/18);
-Up with assist of two staff and Hoyer lift.
Observation on 8/08/18 at 8:28 AM showed the resident lay in bed and the urinary catheter
tubing lay hooked around wheel (caster) and leg of the over the bed table.
Observation on 8/8/18 at 3:19 P.M., showed the following:
-The resident sat in his/her electric scooter (on the Hoyer pad sling) in his/her room.
The catheter bag hung from the chair and the tubing lay on the scooter’s foot rest;
-The Assistant Director Of Nursing (ADON) and CNA D entered the room with the Hoyer lift
and attached the resident’s sling to the mechanical lift;
-CNA D hung the urinary drainage bag from the same hook as the sling. As the resident was
lifted, the drainage bag rose above the level of the resident’s bladder and urine flowed
backward in the tubing toward the insertion site.
During interview on 8/9/18 at 5:05 P.M. CNA D said a urinary drainage bag should not be
raised above the level of the bladder because it would flow back.
6. Review of Resident #11’s care plan dated 8/14/17 showed:
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 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 – Some

(continued… from page 27)
-Problem: Incontinent of bladder and bowel;
-Approach: Provide me with perineal care after each incontinent episode
and monitor for signs and symptoms of urinary tract infection [MEDICAL CONDITION].
Review of the resident’s urinalysis (UA) (a diagnostic lab procedure used to determine
urinary changes and infection), dated 1/17/18, showed the following:
-Appearance: slightly cloudy (normal: clear);
-Epilthelial cells (cells which line the surfaces of the body): 0-5/high power field (hpf)
(normal 0-4);
-[MEDICATION NAME]: positive (presence indicates urinary tract infection)(normal:
negative);
-Mucous: present (normal: negative);
-White blood cells (WBC’s) (cells that fight infection when present in the urine indicate
UTI): 0-5/hpf (normal: 0-4);
-Bacteria: greater than 100/hpf (normal: none).
Review of the nurse’s notes, dated 1/18/18, showed the resident was admitted to the
hospital with [REDACTED].
Review of the urine culture and sensitivity report (diagnostic lab procedure used to
identify the type of bacteria causing an infection and identify the antibiotic medication
appropriate to treat the bacterial infection) dated 1/21/18 showed the following:
-Growth of a gram negative organism;
-Greater than 100,000 organisms per milliliter;
-Heavy growth of Escherichia Coli (E. Coli). Please note; this E. Coli has a sensitivity
with a positive extended-spectrum Beta-Lactamase (ESBL+).
Review of the resident’s discharge summary from the hospital dated 1/23/18 showed the
following:
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] (antibiotic) 500 milligrams (mg) by mouth daily.
Review of the resident’s discharge summary from the hospital dated 4/19/18 showed the
following:
-[DIAGNOSES REDACTED].>-[MEDICATION NAME] Sod-Tazobactam So (broad-spectrum
antibiotic)- 3.375 gram intravenous piggyback every eight hours.
Review of the resident’s quarterly MDS, a federally mandated assessment instrument to be
completed by the facility and dated 5/7/18 showed the following:
-Severely impaired cognition;
-Total dependence of two staff for toilet use and total dependence of one staff for
personal hygiene;
-Always incontinent of bladder and bowel;
-No rejection of care.
Observation on 8/10/18 at 3:47 P.M. showed the following:
-CNA N and CNA O entered the resident’s room to perform perineal care, un-taped the
resident’s urine soiled incontinent brief and rolled the resident to his/her left side;
-CNA N picked up a moistened wash cloth, reached through the resident’s legs to the front
and then pulled it back through. The CNA then repeated the same with a second cloth;
-Staff failed to perform proper perineal care and did not cleanse all soiled areas
including the frontal perineal area, the inner thighs or bilateral groin.
During interview on 8/10/18 at 4:10 P.M., CNA N and CNA O said front perineal care should
be attempted.
During interview on 8/14/18 at 3:45 P.M., CNA X said that when performing perineal care on
the resident, he/she cleaned by turning the resident from side to side and reaching
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 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 – Some

(continued… from page 28)
through (between the legs), wiping front to back.
7. During interview on 8/14/18 at 6:30 P.M. the DON said the following:
-He/she would expect front perineal care to be attempted on residents;
-He/she would expect one staff to hold the resident’s legs and the other to perform the
care;
-If staff cleaned by reaching from behind to the front there would be potential for
bacteria to be pushed forward;
-Staff should provide urinary catheter care every shift and as needed;
-Staff should provide incontinence care and clean the perineal area from front to back,
then clean the urinary catheter tube from insertion site outward. Staff should not wipe
the urinary catheter tube back and forth with one washcloth or wet wipe;
-Staff should keep urinary drainage bags fastened on the resident’s bed frame, off the
floor and below the level of the bladder;
-Staff should not hang the resident’s urinary drainage bag on the top bar of the
mechanical lift and should not allow urine to flow from the urinary catheter tubing back
into the resident’s bladder;
-Staff should not step on the resident’s urinary catheter tubing;
-Staff should not hang the resident’s urinary catheter bag over the bedside table base or
the resident’s wheelchair footrests;
-Staff should provide complete perineal care, incontinence care and catheter care for
residents with contractures or had difficulty spreading legs. Staff should provide frontal
care;
-Ineffective or improper cleansing could lead to urinary tract infections as seen in the
facility.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
Certified Nurse Assistants (CNAs) demonstrated competency in skills and techniques
necessary to care for the residents. Those competencies included areas in basic resident
care skills and appropriate infection control precautions. This failure involved one NA
(Nurse Assistant), five CNAs and the (Assistant Director of Nursing) ADON who provided
direct resident care. The facility census was 57.
1. Observation of NA R on 8/9/18 showed the following:
-At 6:20 A.M. NA R wore gloves and wiped feces from Resident #19’s buttocks;
-Without washing hands or changing gloves NA Rremoved the resident’s gown and placed it on
the floor;
-NA R without washing hands or changing gloves dressed the resident and assisted with a
mechanical lift transfer to the wheelchair;
-NA R without washing hands, changed gloves and applied Resident #10’s (Resident #19’s
roommate’s) clean socks and pants, removed the gloves and without washing hands, obtained
an oxygen portable tank from the closet down the hall, opened a package of oxygen tubing
and attached the oxygen tubing to Resident #19’s oxygen concentrator;
-At 7:00 A.M. NA R without washing hands applied gloves, obtained supplies from the clean
linen cart in the hallway, entered Resident #19’s room and placed the resident’s 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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
catheter drainage bag in a privacy bag, removed the gloves and without washing hands
checked Resident #19’s mouth;
-NA R without washing hands, applied gloves and turned Resident #10 (in the same room) to
his/her side. NA R with the same soiled gloves and without washing hands, obtained wet
wipes and removed small soft feces from the resident’s anal area, obtained a clean wet
wipe and wiped the resident’s buttock areas and did not wash the resident’s urine soiled
hips, thighs, frontal skin folds or perineal area;
-NA R without washing hands and with the same soiled gloves turned the resident side to
side and removed the resident’s urine soiled incontinence brief and dressed the resident;
-NA R without washing hands and with the same soiled gloves transferred the resident to a
wheelchair and combed his/her hair and did not provide the resident oral care or wash
his/her face;
-NA R removed the soiled gloves and without washing hands answered a call light in room
[ROOM NUMBER], obtained clean gloves from the clean linen cart and without washing hands,
applied the gloves and entered room [ROOM NUMBER].
2. Observation of CNA U on 8/7/18 at 3:45 P.M. showed the following:
-CNA U completed Resident #10’s transfer to the wheelchair and without washing hands or
applying gloves attached the mechanical lift sling under resident #19 (Resident #10’s
roommate) to the mechanical lift, removed the resident’s urinary catheter bag from the
side of the bed and hung the urinary catheter bag on the top bar of the mechanical lift,
approximately two feet above the level of the resident’s bladder. Cloudy yellow urine
flowed down the catheter tubing to the resident’s bladder;
-CNA U without washing hands or applying gloves assisted CNA V with Resident #19’s
mechanical lift transfer. The resident’s urinary catheter bag remained hanging on the top
bar of the mechanical lift, approximately two feet above the level of the resident’s
bladder. No urine remained in the catheter tubing. CNA U moved the resident’s urinary
drainage bag containing urine from the top of the mechanical lift bar to the privacy cloth
bag under the resident’s wheelchair, lifted and repositioned the resident in the
wheelchair with the mechanical lift sling under the resident, adjusted the resident’s
shirt and touched the resident’s hair;
-CNA U without washing hands washed Resident #19’s face and hands and without washing
hands adjusted Resident #10’s hair and pushed the mechanical lift into the hallway.
3. Observation of CNA V on 8/7/18 at 3:45 P.M. showed the following:
-CNA V completed Resident #10’s transfer to the wheelchair and without washing hands or
applying gloves attached the mechanical lift sling under Resident #19 (Resident #10’s
roommate) to the mechanical lift, and assisted CNA U with the resident’s mechanical lift
transfer. He/she lifted and repositioned the resident in the wheelchair with the
mechanical lift sling under the resident, obtained washcloths from the clean linen cart in
the hallway and wet the washcloths at the resident’s room sink;
-CNA V without washing hands or applying gloves washed Resident #10’s face, opened the
room door and rolled Resident #19 in his/her wheelchair into the hallway.
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.
-He/she did not know when or how often he/she should wash hands and change gloves;
-He/she should not use the same gloves from one room to the next room;
-He/she should not wear gloves in the hallway;
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
-He/she should not wear soiled gloves and touch other things or touch clean linens;
-He/she thought washing hands when gloves were changed made sense;
-He/she was told to throw soiled linens on the floor and pick up after cares were
provided. He/she now thought linens did not belong the floor.
-The facility provided him/her two days of orientation and then he/she observed a CNA work
with residents for two days. After that he/she was assigned a hall independently.
During interview on 8/9/18 at 4:20 P.M. CNA V said the following:
-He/she washed the resident’s catheter tubing with wet wipes and washed up and down the
catheter tubing from the insertion site;
-He/she washed resident’s perineal area from back to front;
-He/she should place the resident’s urinary catheter bag below the level of the bladder.
Urine running back into the bladder could cause infection.
4. Observation on 8/8/18 at 3:19 P.M. showed the following:
– CNA D and the ADON entered the room, and without washing hands or applying gloves
prepared to transfer Resident #16 to bed. CNA D and the ADON connected the Hoyer sling to
the lift and CNA D picked up and moved the urinary drainage bag (without gloves) from the
chair to the lift arm (raising it above the level of the bladder and allowing it to
backflow into the resident’s bladder);
-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;
-The resident was transferred to bed and CNA D and the ADON rolled the resident to remove
the sling;
-The ADON, without washing his/her hands exited the room;
-CNA D washed his/her hands, gloved, retrieved a gown, removed the resident’s soiled top,
applied the gown, rolled the resident, pulled the ressident’s pants down and removed the
dry incontinent brief. He/she picked up the catheter bag, threaded it through the
resident’s pant leg, removed the pants and tossed them along with other linens on the
floor.;
-CNA D degloved and without washing hands exited the room;
-CNA D re-entered the room with a clean sheet, covered the resident, picked up the linens
from the floor and exited without washing his/her hands.
During interview on 8/9/18 at 5:05 P.M., CNA D said the following:
-He/she did know that 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
had a second staff pull the resident back away from the bar.
5. Observation on 8/10/18 at 3:47 P.M. showed the following:
-CNA N and CNA O entered Resident #11’s room to perform perineal care, un-taped the
resident’s urine, soiled incontinent brief and rolled the resident to his/her left side;
-CNA N picked up a moistened wash cloth, reached through the resident’s legs to the front
and then pulled it back through. The CNA then repeated the same with a second cloth;
-Staff failed to perform proper perineal care and did not cleanse all soiled areas
including the frontal perineal area, the inner thighs and groin.
During interview on 8/10/18 at 4:10 P.M., CNA N and CNA O said frontal perineal care
should be attempted.
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said the following:
-New NA staff receive six days of orientation and work with another CNA. No other training
was provided for the NA staff and no skills check offs were completed prior to NAs
providing resident care independently;
-All NA and CNA staff currently needed skills check offs to ensure appropriate care was
provided;
-Untrained staff and inappropriate care resulted in poor quality of care.
During interview on 8/14/18 at 5:30 P.M., the administrator said the following:
-There is no one following CNAs to ensure they are transferring correctly and washing
hands;
-He/she was aware of the 16 hours required for the CNA program;
-The faciility does not have a policy for CNA competency.

F 0758

Level of harm – Actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure one resident (Resident
#4) did not receive antipsychotic medications without thorough documentation to identify
the indication for use. The resident received [MEDICATION NAME] (an antipsychotic
medication) to treat a [DIAGNOSES REDACTED]. The resident also received [MEDICATION NAME]
(an antipsychotic medication) as needed for agitation, however, the facility failed to
provide a specific [DIAGNOSES REDACTED]. of the resident and of indications, specific
circumstances for use, and the desired frequency of administration. Resident #4 received
two antipsychotic medications which were not approved for use in psychotic conditions
related to dementia and were labeled to potentially increase the risk of death in older
adults with dementia-related conditions. While receiving antipsychotic medications, the
resident was admitted to the hospital with [REDACTED]. The facility also failed to ensure
one sampled resident’s (Resident #16) and one additional resident’s (Resident #28)
physician orders for as needed (PRN) [MEDICAL CONDITION] drugs were limited to 14 days as
required except if an attending or prescribing physician believed that it was appropriate
for the PRN order to be extended beyond 14 days, then the physician should document their
rationale in the resident’s medical record and indicate the duration for the PRN order, in
a review of 16 sampled residents. The facility census was 57.
1. Review of the facility policy Pharmacy Consultant Expectations dated (YEAR) showed the
following:
-The overall goal of the pharmaceutical services system within a facility was to ensure
the safe and effective use of medications;
-The intent was that the facility maintained the resident’s highest practicable level of
physical, mental and psychosocial well being and prevented or minimized adverse
consequences related to medication therapy to the extent possible, by providing oversight
by a licensed pharmacist, attending physician, medical director, and the director of
nursing;
-The facility implemented gradual dose reductions and non-pharmacological interventions,
unless contraindicated, prior to initiating or instead of continuing [MEDICAL CONDITION]

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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 32)
medication;
-PRN orders for [MEDICAL CONDITION] medications were only used when the medication was
necessary and PRN use was limited.
2. Review of the facility policy Antipsychotic Medication Use, dated(NAME)(YEAR), showed
the following:
-Residents will only receive antipsychotic medications when necessary to treat specific
conditions for which they are indicated and effective;
-The attending physician and other staff will gather and document information to clarify a
resident’s behavior, mood, function, medical condition, symptoms and risks;
-The attending physician and facility staff will identify acute psychiatric episodes, and
will differentiate them from enduring psychiatric conditions;
-Nursing staff will document in detail an individual’s target symptoms;
-The attending physician will identify, evaluate and document, with input from other
disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic
medications;
-Staff will observe, document, and report to the physician information regarding the
effectiveness of any interventions, including antipsychotic medications;
-Based on assessing the resident’s symptoms and overall situation, the physician will
determine whether to continue, adjust, or stop existing antipsychotic medications;
-Antipsychotic medications shall only be used for the following conditions/diagnoses as
documented in the record: Schizo-affective disorder, mood disorders, depression with
psychotic features, [MEDICAL CONDITION], brief [MEDICAL CONDITIONS], delusional disorder,
schizophreniform disorder, atypical [MEDICAL CONDITION], dementing illnesses with
associated behavioral symptoms, and medical illnesses or [MEDICAL CONDITION] with manic or
psychotic symptoms;
-For enduring psychiatric conditions, antipsychotic medications will not be used unless
behavioral symptoms are:
-Not due to a medical condition that can be expected to improve or resolve as the
underlying condition is treated; and
-Persistent of likely to reoccur without continued treatment; and
-Not sufficiently relieved by non-pharmacological interventions; and
-Not due to environmental stressors that can be addressed;
-Not due to psychological stressors that can be expected to improve or resolve as the
situation is addressed.
-Antipsychotic medications will not be used if the only symptoms are one or more of the
following: wandering, poor self-care, restlessness, impaired memory, mild anxiety,
[MEDICAL CONDITION], unsociability, inattention, fidgeting, nervousness,
uncooperativeness, verbal expressions or behavior that are not due to conditions listed
under indications and do not represent a danger to the resident or others.
3. Review of drugs.com showed the following for [MEDICATION NAME]:
-[MEDICATION NAME] is an antipsychotic medicine;
-[MEDICATION NAME] is indicated for use in the treatment of [REDACTED].
-[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia.
This medicine may increase the risk of death in older adults with dementia-related
conditions.
Review of drugs.com showed the following for [MEDICATION NAME]:
-[MEDICATION NAME] is an antipsychotic medicine;
-[MEDICATION NAME] is used to treat [MEDICAL CONDITION] and is also used to treat symptoms
of [MEDICAL CONDITION] disorder;
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 33)
-[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. It
may increase the risk of death in older adults with dementia-related conditions.
4. Review of Resident #4’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety;
-[MEDICATION NAME] (an antipsychotic medication) 0.25 milligrams (mg) every morning for
delusional disorder (original order dated 7/18/17);
-[MEDICATION NAME] 1 mg at bedtime (original order dated 9/15/17);
-[MEDICATION NAME] (an antianxiety medication) 15 mg twice daily (original order dated
9/11/17);
-[MEDICATION NAME] (an antianxiety medication) 1 mg every six hours as needed (PRN) for
anxiety and aggressiveness (original order dated 7/7/17).
Review of the resident’s physician progress notes [REDACTED].
-Family wants the resident off of [MEDICATION NAME]. Discontinue [MEDICATION NAME] and
change to [MEDICATION NAME] for self-protection and agitation. Decrease [MEDICATION NAME];
-The resident is confused and easily agitated;
-[DIAGNOSES REDACTED].
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed new orders were
received on 10/12/17 for the following:
-Discontinue [MEDICATION NAME];
-Decrease [MEDICATION NAME] at bedtime to 0.75 mg;
-Add [MEDICATION NAME] 2 mg every six hours PRN for agitation.
Review of the resident’s [MEDICAL CONDITION] monitoring record showed the resident had
paranoia on the 3:00 P.M. to 11:00 P.M. shift on 10/13/17. (This was the only day staff
documented the resident had paranoia in (MONTH) (YEAR). There was no documentation to show
the resident had delusions.)
Review of the resident’s Medication Administration Record (MAR), dated (MONTH) (YEAR),
showed on 10/13/17 at 4:35 P.M., staff administered PRN [MEDICATION NAME] for increased
anxiety and agitation.
Review of the resident’s nurses notes, dated 10/13/17, showed no evidence the resident
received PRN [MEDICATION NAME] as documented in the MAR, and no documentation of
non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION
NAME] on this day.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 10/14/17, showed the
following:
-Usually understood others;
-Usually able to make himself/herself understood;
-Severe cognitive impairment;
-Inattention present, but fluctuates;
-No behaviors, no delusions, and no hallucinations;
-Diagnoses included dementia and anxiety;
-No [DIAGNOSES REDACTED].
-Received antipsychotic and antianxiety medications on all days in the seven-day look back
period;
-Antipsychotic medications received on a routine basis.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/14/18 at 9:30 A.M., staff
administered PRN [MEDICATION NAME], however, staff did not document the reason the
medication was given.
Review of the resident’s nurses notes, dated 10/14/17 at 11:54 P.M., showed the resident
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 34)
had periods of restlessness earlier this shift; he/she was difficult to redirect. Will
continue to monitor. (Review showed no evidence the resident received PRN [MEDICATION
NAME] as documented in the MAR, and no documentation of non-pharmacological interventions
attempted prior to administration of the PRN [MEDICATION NAME] on this day.)
Review of the resident’s care plan, dated 10/17/17, showed the following:
-[DIAGNOSES REDACTED].
-[MEDICAL CONDITION] medication use: Give [MEDICATION NAME] (an antipsychotic medication)
scheduled and [MEDICATION NAME] (an antipsychotic medication) as needed for increased
anxiety. The resident is at risk for side effects from his/her medications.
-The resident will be free from adverse affects or worsening symptoms related to the use
of [MEDICAL CONDITION] medications;
-Assess the resident for any changes in his/her behaviors or moods;
-Notify the physician of status changes;
-The pharmacist and physician are to review record and assess the effectiveness of
medication, and routinely assess for possible decreased dose or discontinuation of
medication.
-The resident is forgetful and confused and does not always understand what is going on
around him/her or where he/she is at. He/she has made threats and gestures to hit at staff
and can be resistive to care. The resident has a [DIAGNOSES REDACTED].>-Provide the
resident with frequent reorientation;
-Allow resident time to comprehend what is said;
-Do not confront or argue with the resident. Attempt to interest the resident in a
diversional activity with decreased stimuli;
-If the resident becomes aggressive during care, stop and explain what you are doing and
why, allow the resident time to calm down.
-If unable to calm the resident and he/she remains resistive, assure him/her he/she is in
a safe environment and leave the room to let him/her calm down and reapproach later. If
he/she still resists, have someone else try to assist him/her;
-Encourage socialization and activities. Offer toileting and activities;
-Notify charge nurse of the resident’s unresolved behaviors and the resident’s family
member who may come to help decrease the resident’s agitation;
-Administer [MEDICATION NAME] (an antipsychotic medication) scheduled and [MEDICATION
NAME] as ordered;
-Notify the physician of changes in mood or behaviors that are unresolved.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/22/17 at 2:00 P.M., staff
administered PRN [MEDICATION NAME], however, staff did not document the reason the
medication was given.
Review of the resident’s nurses notes, dated 10/22/17 at 4:43 P.M., showed the resident
was displaying increased agitation and was difficult to redirect. Staff gave the resident
PRN [MEDICATION NAME] per physician orders with no further negative behaviors. (Review
showed no documentation of non-pharmacological interventions attempted prior to
administration of the PRN [MEDICATION NAME].)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 10/30/17 at 3:30 P.M., staff
administered PRN [MEDICATION NAME], however, staff did not document the reason the
medication was given.
Review of the resident’s nurses notes dated 10/30/17 showed no evidence the resident
received PRN [MEDICATION NAME] as documented on the MAR, and no documentation of
non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION
NAME] on this day.
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 35)
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety;
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 11/6/17 at 6:00 P.M., staff
administered PRN [MEDICATION NAME] for agitation.
Review of the resident’s nurses notes, dated 11/6/17, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 11/20/18 at 11:00 P.M.,
staff administered PRN [MEDICATION NAME], however, staff did not document the reason the
medication was given.
Review of the resident’s PRN Anti-anxiety, Anti-Psychotic, and Hypnotic Documentation,
dated 11/20/17, showed the following:
-Non-pharmacological interventions attempted: Calm resident, offer bathroom, and offer
food;
-PRN [MEDICATION NAME] given at 11:00 P.M. for agitation.
Review of the resident’s nurses notes, dated 11/20/17, showed no documentation for the
resident on this day.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following:
-On 11/21/18 at 11:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did
not document the reason the medication was given;
-On 11/22/18 at 5:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did
not document the reason the medication was given.
Review of the resident’s nurses notes for 11/21/18 and 11/22/18, showed no documentation
for the resident on these days. There was no evidence non-pharmacological interventions
were attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed on 11/22/17, the resident had on delusions the 3:00 P.M. to 11:00 P.M. shift.
(There was no documentation to show the resident presented with delusions on other days
during (MONTH) (YEAR).)
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not
indicate the duration of this PRN order.)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following:
-On 12/11/17 at 4:30 A.M., staff administered PRN [MEDICATION NAME] for agitation;
-On 12/14/17 at 8:00 A.M., staff administered PRN [MEDICATION NAME] for anxiety and
agitation.
Review of the resident’s nurses notes, dated 12/11/17 and 12/14/17, showed no
documentation for the resident on these days. There was no evidence non-pharmacological
interventions were attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s physician’s progress notes, dated 12/14/17, showed the following:
-The physician saw the resident;
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 36)
-The resident has increased confusion;
-The resident’s medical record and medications were reviewed;
-Diagnoses of confusion and multi infarct dementia;
-Continue current therapy.
(Review showed no evidence the resident’s physician evaluated the indication for use,
specific circumstances for use, benefits for continued use and the desired frequency of
administration of the PRN [MEDICATION NAME].)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 12/29/17 at 5:00 P.M., staff
administered PRN [MEDICATION NAME], however, staff did not document the reason the
medication was given.
Review of the resident’s nurses notes, dated 12/29/17, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed no evidence the resident had delusions during the month.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety;
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not
indicate the duration of this PRN order.)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 1/8/18 at 7:00 A.M., staff
administered PRN [MEDICATION NAME] for combative behavior, uncooperative, and unable to
redirect.
Review of the resident’s nurses notes, dated 1/8/18, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s physician’s progress notes, dated 1/11/18, showed the following:
-The physician saw the resident and reviewed his/her medical record and medications;
-Staff reported no new changes;
-Diagnoses of confusion and multi infarct dementia;
-Continue current treatment.
(Review showed no evidence the resident’s physician evaluated the indication for use,
specific circumstances for use, benefits for continued use and the desired frequency of
administration of the PRN [MEDICATION NAME].)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 1/13/18 at 1:05 P.M., staff
administered PRN [MEDICATION NAME] for agitation.
Review of the resident’s nurses notes, dated 1/13/18, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the pharmacist consultation report, dated (MONTH) (YEAR), showed the following:
-Recommendation to discontinue the PRN [MEDICATION NAME]. The physician declined the
recommendation and wrote, the resident has post head trauma with episodic outbreaks
requiring medication. The physician signed and dated the consultation report on 2/13/18;
-The resident received [MEDICATION NAME] 0.25 mg A.M. and 0.75 mg P.M. since 10/12/17,
when it was reduced. This reduction seems successful. Please consider gradual dose
reduction to 0.25 mg A.M. and 0.5 mg P.M. while monitoring for emergence of target and/or
withdrawal symptoms. The physician declined the recommendation because a reduction was
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 37)
clinically contraindicated. Continued use of the medication was in accordance with current
standards of practice and an reduction attempt is likely to impair the individual’s
function or cause psychiatric instability by exacerbating an underlying medical condition
of psychiatric disorder as documented below (space below was left blank).
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Usually understood others;
-Usually able to make himself/herself understood;
-Severe cognitive impairment;
-Inattention present, but fluctuates;
-Disorganized thinking continuously present, does not fluctuate;
-No behaviors, no delusions, and no hallucinations;
-Diagnoses included dementia and anxiety;
-No [DIAGNOSES REDACTED].
-Received antipsychotic and antianxiety medications on all days in the seven-day look back
period;
-Antipsychotic medications received on a routine basis.
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed no evidence the resident had delusions during the month.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not
indicate the duration of this PRN order.)
Review of the resident’s physician’s progress note, dated 2/8/18, showed the following:
-The physician saw the resident and reviewed his/her medical record and medications;
-The resident was confused;
-Diagnoses of confusion and multi infarct dementia;
-Continue current therapy.
(Review showed no evidence the resident’s physician evaluated the indication for use,
specific circumstances for use, benefits for continued use and the desired frequency of
administration of the PRN [MEDICATION NAME].)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 2/23/18 at 4:00 P.M., the
resident received PRN [MEDICATION NAME] for agitation.
Review of the resident’s nurses notes, dated 2/23/18, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed no evidence the resident had delusions during the month.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder and anxiety;
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician’s orders did not
indicate the duration of this PRN order.)
Review of the resident’s PRN Antianxiety, Antipsychotic, and Hypnotic Documentation, dated
3/4/18 at 6:15 A.M., the resident was hitting other residents and staff. He/she was
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 38)
restless, loud, hollering, rude, making verbal threats, scaring and upsetting other
residents, taunting and aggravating other residents, and kicking chairs. Staff attempted
to calm the resident; reorient the resident; offer water, bathroom, and food; reposition
the resident; offer pain medication; and waited a few minutes and tried again. PRN
[MEDICATION NAME] was given at 7:00 A.M.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 3/4/18 at 7:00 A.M., staff
administered PRN [MEDICATION NAME].
Review of the resident’s physician’s progress notes, dated 3/8/18, showed the following:
-The physician saw the resident and reviewed his/her medical record and medications;
-The resident was very confused;
-Diagnoses of confusion and multi infarct dementia;
-Continue with current therapy.
(Review showed no evidence the resident’s physician evaluated the indication for use,
specific circumstances for use, benefits for continued use and the desired frequency of
administration of the PRN [MEDICATION NAME].)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 3/30/18 at 7:15 A.M., staff
administered PRN [MEDICATION NAME] for agitation.
Review of the resident’s nurses notes, dated 3/30/18, showed no documentation for the
resident on this day. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME].
Review of the pharmacist consultation report, dated for (MONTH) (YEAR), showed the
following:
-The resident has a PRN order for an antipsychotic, which has been in place for greater
than 14 days without a stop date. [MEDICATION NAME] 2 mg every six hours as needed for
agitation.
-Recommendation- Please review and discontinue PRN [MEDICATION NAME]. If this PRN
antipsychotic cannot be discontinued at this time, current regulations require that the
prescriber directly examine the resident to determine if the antipsychotic is still needed
and document the specific condition being treated prior to issuing a new PRN order.
-Rationale for recommendation: CMS requires that PRN orders for antipsychotic medications
be limited to 14 days. A new order should not be written without the prescriber directly
examining the resident and assessing the resident’s condition and progress to determine if
the PRN antipsychotic is still needed. Report of the resident’s condition from facility
staff to the prescriber does not meet the criteria for an evaluation.
-The physician marked he/she declined the recommendation above and did not wish to
implement any changes due to the reasons below. The physician wrote to continue the PRN
for severe change in mood with self-harm environment (illegible).
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed no evidence the resident had delusions during the month.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder and anxiety;
-[MEDICATION NAME] 0.25 mg every morning for delusional disorder;
-[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime;
-[MEDICATION NAME] 15 mg twice daily;
-[MEDICATION NAME] 2 mg every six hours PRN for agitation. Handwritten note, dated 4/2/18,
showed to continue PRN for severe change in mood with self-harm. (The physician’s orders
did not indicate the duration of this PRN order.)
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Usually understood others;
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 39)
-Usually able to make himself/herself understood;
-Severe cognitive impairment;
-Inattention present, but fluctuates;
-Disorganized thinking continuously present, does not fluctuate;
-No behaviors, no delusions, and no hallucinations;
-Diagnoses included dementia and anxiety;
-No [DIAGNOSES REDACTED].
-Received antipsychotic and antianxiety medications on all days in the seven-day look back
period;
-Antipsychotic medications received on a routine basis.
Review of the resident’s nurses notes showed the following:
-On 4/17/18 at 7:20 A.M., the resident sat in his/her chair, leaning forward to the point
of almost falling out of his/her chair. The resident was jerking all over upper and lower
extremities and torso. Did not answer to verbal stimuli, moaned at intervals.
-On 4/17/18 at 7:54 A.M., the resident was transported to the hospital.
-On 4/19/18 at 1:04 P.M., the resident returned to the facility.
Review of the resident’s hospital discharge summary, dated 4/19/18, showed the resident
was admitted from a nursing home secondary to changes in behavior. The resident has
advanced dementia with behavioral issues. The resident’s [MEDICATION NAME] was stopped
secondary to tardive dyskinesia (a condition affecting the nervous system, often caused by
long-term use of psychiatric medications).
Review of the patient transfer form from the hospital, dated 4/19/18, showed to
discontinue [MEDICATION NAME] secondary to tardive dyskinesia
Review of the resident’s physician’s orders, dated 4/19/18, showed the following:
-Discontinue [MEDICATION NAME] and [MEDICATION NAME];
-Handwritten note added on 4/19/18 to restart [MEDICATION NAME] 0.25 mg, three tablets at
bedtime.
Review of the resident’s physician progress notes [REDACTED]. There was no further
documentation in the note. (Review showed no evidence the resident’s physician evaluated
the indication for use, specific circumstances for use, benefits for continued use and the
desired frequency of administration of the PRN [MEDICATION NAME]. The medical record did
not include documentation to support adding [MEDICATION NAME] 0.25, three tablets at
bedtime.)
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed no evidence the resident had delusions during the month.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed an order for
[REDACTED]. Further review showed no physician order for [REDACTED].
Review of the resident’s History and Physical, dated 5/10/18, showed the following:
-Medical diagnoses included Alzheimer’s dementia and recurrent UTIs;
-Resident is confused;
-Resident’s behavior is appropriate.
(Review showed no documented evidence to address the resident’s medication regimen.)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following:
-[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors. (Review of the
resident’s physician’s orders showed no evidence the resident had an order for [REDACTED].
-On 5/22/18 at 9:40 A.M., staff administered PRN [MEDICATION NAME]. The resident was
yelling, hitting, and fighting with staff and family;
-On 5/25/18 at 1:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was
hitting and trying to stand;
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 40)
-On 5/25/18 at 9:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was
yelling and hitting; very agitated;
-On 5/27/18 at 8:30 P.M., staff administered PRN [MEDICATION NAME]. The resident had
increase agitation, and was yelling and hitting;
-On 5/28/18 (time illegible), staff administered PRN [MEDICATION NAME]. The resident was
agitated and hitting. The medication helped the resident stay busy;
-On 5/28/18 at 2:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was
agitated and had aggression.
(Review showed no evidence staff documented the effectiveness of the medication, except
for on 5/28/18.)
Review of the resident’s nurses notes for (MONTH) (YEAR) showed no evidence the resident
had delusions, aggression, agitation, or any physical or verbal behaviors directed towards
others during the month. There was no evidence non-pharmacological interventions were
attempted prior to the administration of the PRN [MEDICATION NAME] during (MONTH) (YEAR).
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the following:
-Diagnoses included dementia, delusional disorder, and anxiety;
-[MEDICATION NAME] 0.25 mg, take three tablets (0.75 mg) at bedtime;
-[MEDICATION NAME] 2 mg every six hours as needed for agitation. (The physician’s orders
did not indicate the duration of this PRN order.)
Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following:
-[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors;
-On 6/4/18 at 6:30 A.M., staff administered [MEDICATION NAME] for agitation;
-On 6/5/18 at 3:25 A.M., staff administered [MEDICATION NAME] for agitation and yelling;
-On 6/5/18 at 11:30 P.M., staff administered [MEDICATION NAME], however, staff did not
document the reason the medication was given.
Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the
resident on 6/4/18 and 6/5/18(when staff administered PRN [MEDICATION NAME]). There was no
evidence non-pharmacological interventions were attempted prior to the administration of
the PRN [MEDICATION NAME].
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 6/8/18 at 2:00 A.M., showed
staff administered [MEDICATION NAME] for yelling.
Review of the resident’s [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR),
showed on 6/8/18 on the 7:00 A.M. to 3:00 P.M. shift, showed the resident presented with
delusions.
Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the
resident on 6/8/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence
non-pharmacological interventions were attempted prior to the administration of the PRN
[MEDICATION NAME].
Review of the resident’s MAR, dated (MONTH) (YEAR), showed on 6/10/18 at 10:45 A.M., staff
administered [MEDICATION NAME] for agitation and yelling.
Review of the resident’s nurses notes for (MONTH) (YEAR) showed no documentation for the
resident on 6/10/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence
non-pharmacological inter

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**
Based on observation, interview and record review the facility failed to ensure 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 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 41)
medication error rate was less than five percent. Thirty five opportunities were observed
with two medication errors, resulting in a medication error rate of 5.7 percent. The
facility census was 57.
1. Review of the facility policy Medication, Administration Guidelines from Nursing
Guidelines Manual, (MONTH) (YEAR), showed the following:
-The purpose was that residents received their mediations on a timely basis and in
accordancew the established policies;
-Medications were given to benefit a resident’s health as ordered by the physician;
-For administration of tablets or capsules offer resident water before/after administering
medication to aid in swallowing, do not crush any medication if a liquid form was
available. Certain medications should never be crushed, refer to pharmacy manual if unsure
if a medication could be crushed.
2. Review of www.drugs.com showed the following:
-[MEDICATION NAME], an anti-epileptic drug used to treat partial onset [MEDICAL
CONDITION], swallow the tablet whole and do not crush, chew or break it;
-Potassium chloride, a mineral found in many foods and was needed for several functions of
your body especially the beating of the heart, swallow the pill whole, do not crush, chew,
break or suck on an extended-release tablet or capsule. Breaking or crushing the pill may
cause too much of the drug to be released at one time.
3. Review of Resident #21’s Physician Order Sheet dated (MONTH) (YEAR) showed the
following:
-[MEDICATION NAME] (blood pressure medication) 25 milligrams (mg) one tablet two times
daily at 8:00 A.M. and 5:00 P.M.;
-[MEDICATION NAME] ([MEDICATION NAME] medication used to improve blood flow in the legs)
100mg one tablet two times daily at 8:00 A.M. and 5:00 P.M.;
-[MEDICATION NAME] 750 mg one tablet two times daily at 8:00 A.M. and 5:00 P.M.;
-[MEDICATION NAME] (diabetic medication) 500 mg one tablet two times daily at 8:00 A.M.
and 4:00 P.M.;
-KCL (potassium chloride) 20 milliEquivalent (mEq) extended release one tablet two times
daily at 8:00 A.M. and 5:00 P.M.
Observation on 8/8/18 at 3:30 P.M. showed the following:
-Certified Medication Technician (CMT) O obtained [MEDICATION NAME] 25 mg one tablet,
[MEDICATION NAME] 100mg one tablet, [MEDICATION NAME] 750mg one tablet, [MEDICATION NAME]
500mg one tablet and KCL 20 mEq one tablet from the medication cart drawer, placed all the
medications in a plastic sleeve and crushed the medications;
-CMT O poured the crushed medication powder into a medication cup, added applesauce and
administered the medications;
-CMT O did not administer [MEDICATION NAME] and KCL whole.
During interview on 8/10/18 at 2:35 P.M. and 8/14/18 at 2:20 P.M. CMT O said the
following:
-He/she learned yesterday not to crush potassium chloride. He/she did not know that
before. Currently he/she crushed all potassium chloride medications if the resident was
unable to swallow the medication whole;
-He/she was not aware [MEDICATION NAME] medication should not be crushed. He/she always
crushed [MEDICATION NAME] if the resident was unable to swallow the medication whole.
During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said staff should not
crush potassium chloride tablets or [MEDICATION NAME] medications. If the resident was
unable to swallow the medications whole, staff should contact the physician for a
different form of the medication to administer.
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 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

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 observation, interview and record review staff failed to timely return to the
pharmacy or destroy discontinued medications for 11 additional discharged or expired
residents (Residents #1, #7, #200, #201, #202, #203, #204, #205, #206, #207, and #208).
The facility census was 57.
1. Review of the facility’s Medications, Destruction of policy from the Nursing Guidelines
Manual dated (MONTH) (YEAR), showed the following:
-The facility will destroy and dispose of medications in a safe manner and in accordance
to applicable law;
-All medications not returned to the issuing pharmacy will be destroyed;
-Two licensed nurses or one licensed nurse and facility pharmacist will destroy all
medications, except controlled substances which will require Director of Nursing (DON)
supervision;
-Documentation of medication destruction will include: date, name of medication,
prescription number, amount of medication destroyed, method of destruction, and signatures
of nurses and/or pharmacist;
-Scheduled II-IV medication will be destroyed as stated above with the following
exceptions, the controlled medication count sheet will include the following information:
signature of nurses and/or pharmacist destroying medication, amount destroyed, and date
destroyed;
-Medications to be destroyed including pills, capsules, liquids, creams etc will be placed
in sealable container such as a plastic bag;
-An unpalatable substance such as kitty litter or used coffee grounds will be added to the
plastic bag of medications;
-Before sealing plastic bag, approximately one cup of fluid (i.e. water, liquid detergent
etc.) will be added to the plastic bag of medications;
-The plastic bag will then be sealed and placed in the trash (Red bag not required).
Review of the facility’s Medications, Storage of policy from the Nursing Guidelines
Manual dated (MONTH) (YEAR), showed the following:
-All medications for residents must be stored at or near the nurse’s station in a locked
cabinet, a locked medicine room or one or more locked mobile medication carts;
-No discontinued, outdated or deteriorated drugs or biologicals may be retained for use.
All such drugs must be returned to the issuing pharmacy or destroyed in accordance with
established guidance.
3. Observation of the A Hall medication room on 8/9/18 at 12:40 P.M. showed the following:
-Two large cardboard boxes sat on the medication room counter and contained multiple
medication bottles, prescription blister dispensing medication cards and vials of
medications;
-The two large cardboard boxes contained the following:
-[MEDICATION NAME] (antacid medication) 1 gram, 30 tablets dispensed 7/5/18 belonging to
discharged Resident #1 (discharged on [DATE]);
-[MEDICATION NAME] (gout medication) 100 milligrams (mg), 30 tablets dispensed 3/30/18 and
Atorvastatin (cholesterol medication) 10mg, 29 tablets dispensed 3/30/18 belonging to

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 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 43)
expired Resident #208 (expired on 6/8/18);
-Pantoprazole (medication used to treat gastric reflux) 40 mg, 20 tablets dispensed
5/21/18 and discontinued on 6/5/18, [MEDICATION NAME] (antacid medication) 150mg
approximately 100 tablets, medication expired on 6/21/18, belonging to Resident #7;
-[MEDICATION NAME] (medication used to treat dementia) 10 mg, 28 tablets dispensed 6/12/18
belonging to expired Resident #206 (expired on 6/25/18);
-[MEDICATION NAME] (antipsychotic medication) 5mg/milliliter (ml) 2 vials dispensed
6/27/14 and expired in (MONTH) (YEAR) belonging to expired Resident #204 (expired on
1/4/15);
-[MEDICATION NAME] 5mg/ml 3 vials dispensed 8/19/16 and expired in (MONTH) (YEAR)
belonging to expired Resident #203 (expired on 1/13/17);
-[MEDICATION NAME] Lock Flush (blood thinning medication) 16-5ml syringes dispensed
2/20/18 belonging to expired Resident #202 (expired on 5/20/18);
-[MEDICATION NAME] 2mg/ml, 15ml liquid bottle dispensed 5/18/18 and [MEDICATION NAME]
(anti -nausea medication) 10 mg, 3 tablets dispensed on 5/18/18 belonging to expired
resident #201, (expired on 5/30/18);
-[MEDICATION NAME] (neurological pain medication) 100 mg, 270 capsules dispensed on
6/11/18 belonging to discharged Resident #200 (discharged on [DATE]);
-[MEDICATION NAME] suspension (liquid medication used for oral yeast infection) 100,000
units/ml, approximately 60 ml bottle dispensed 6/26/18 and [MEDICATION NAME] (liquid
breathing medication) 0.5mg/3mg/3ml, 30 vials dispensed 6/26/18 belonging to expired
Resident #205 (expired on 7/2/18);
-[MEDICATION NAME] 2mg/ml, 20 ml bottle dispensed 5/25/18, Senna (laxative medication) 8.6
mg, 14 tablets dispensed 5/10/18, [MEDICATION NAME] (anti-depressant medication) 50mg, 24
tablets dispensed 4/2/18, [MEDICATION NAME] (muscle relaxant medication) 10mg, 22 tablets
dispensed on 4/2/18 belonging to expired Resident #207 (expired on 6/10/18);
-Influenza Vaccine 2.5 vials expired 6/30/18.
During interview on 8/9/18 at 1:00 P.M. Certified Medication Technician (CMT) X said staff
should destroy or return to pharmacy all discontinued medications and expired medications
within a few days. Staff should destroy or return to pharmacy all medications belonging to
discharged or expired residents immediately after discharge or death.
During interview on 8/14/18 at 6:30 P.M. the Director of Nursing said the following:
-Staff should destroy residents’ medications at the time the resident was discharged or
expired. Currently staff placed medications for destruction under the sink in a box in the
medication room until destroyed;
-Staff should not keep medications no longer needed past 30 days;
-There was no designated person to destroy medications.

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 ensure meals
were served to meet the needs of the residents. The facility failed to follow the menu for
serving sizes for eight of eight residents on a pureed diet (Resident #7, 11, 19, 25, 28,
213, 214, and 215) by failing to give the correct number of scoops of protein to any
resident in accordance with the facility spreadsheet. The facility census was 57.

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 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 44)
1. Review of the facility spread sheet for the lunch meal service on 8/7/18 showed two #10
scoops of mashed potatoes were to be served to residents on a pureed diet.
Observations on 08/07/18 between 11:42 A.M. and 12:18 P.M. during the lunch time meal
service showed the following:
-A #10 (3.25 oz) scoop was used to serve mashed potatoes;
-One scoop of mashed potatoes was served to Resident #7;
-One scoop of mashed potatoes was served to Resident #11;
-One scoop of mashed potatoes was served to Resident #19;
-One scoop of mashed potatoes was served to Resident #25;
-One scoop of mashed potatoes was served to Resident #28;
-One scoop of mashed potatoes was served to Resident #213;
-One scoop of mashed potatoes was served to Resident #214;
-One scoop of mashed potatoes was served to Resident #215;
During interview on 08/07/18 at 1:59 P.M., the dietary supervisor said the spread sheet
calls for two #10 scoops of mashed potatoes, and two scoops should have been given to each
resident on a pureed diet.
During interview on 8/8/18 at 9:06 A.M., the registered dietician said the correct serving
size for mashed potatoes for the lunch meal on 8/7/18 should have been two #10 scoops.
This portion was carefully calculated in order to ensure proper nutrition was met for each
resident.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure staff
washed their hands after each direct resident contact and when indicated by professional
practices during personal care for eight of 16 sampled residents (Residents #10 ,#11, #12,
#16, #18, #19, #110 and #111) and one additional resident (Residents #8) and failed to
ensure proper linen sanitation practices were followed. The facility also failed to
disinfect a glucometer (device used to check blood glucose levels) used for multiple
residents, according to acceptable infection control practice. The facility census was 57.

1. Review of the facility policy Blood Glucometer disinfecting dated (MONTH) (YEAR) showed
the following:
-The purpose was to prevent the spread of infection;
-Equipment was approved wipes with 10 percent bleach or comparable product;
-Wash hands and apply gloves, provide a clean field in which to place the glucose meter
such as a paper towel. Clean the blood glucose meter prior to using with approved wipes
with 10 percent bleach or comparable product, place on a clean field and let air dry
according to manufacturer’s directions. Do not touch the clean field with gloves including
the test port. Glucometer could be wrapped in another wipe and stored. Remove gloves and
wash hands.
2. Review of the facility policy Gloves dated (MONTH) (YEAR) showed the following:
-Wear gloves when reasonably anticipated that hands would be in contact with mucous
membranes, non-intact skin, any moist body substances and /or persons with a rash. Gloves
must be changed between residents and between contact with different body sites of the
same resident;

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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
-Gloves were not a cure-all. They should reduce the likelihood of contaminating the hands
but gloves could not prevent penetrating injuries due to needles or sharp objects. Dirty
gloves were worse than dirty hands because microorganisms adhere to the surface of the
glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves was not acceptable.
3. Review of the facility policy Handwashing dated (MONTH) 2012 showed handwashing
remained the single most effective means of preventing disease transmission. Wash hands
often and well, paying particular attention to areas around and under the fingernails and
between fingers. Wash hands whenever they were soiled with body substances, before food
preparation, before eating, after using the toilet, before performing invasive procedures
and when each resident’s care was competed.
4. Review of the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005
edition, Section 3.0, Body Substance Precautions, Subsection 3.2 Implementing the Body
Substance Precautions System, showed the following regarding gloves and handwashing:
-Instructions should be followed by ALL personnel at all times regardless of the
resident’s diagnosis;
-Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact
with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces,
wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances) and/or persons with a rash; gloves must be changed between residents and
between contacts with different body sites of the same resident.
Section 3.0: Body Substance Precautions Subsection 3.2 Implementing the Body Substance
Precautions System INFECTION CONTROL GUIDELINES FOR LONG TERM CARE FACILITIES
Guidelines for appropriate management of soiled linen include:
? Place all soiled linens in laundry bags provided at the point of use.
? Avoid contact with your uniform/clothing and surrounding patient care equipment.
? Do not shake or place linen directly on the floor.
? For linens lightly to moderately moist, fold and/or roll in such a way as to contain the
moist area in the center of the soiled linen.
? For soiled linens that are saturated with moisture, place them in a plastic bag followed
by tying or knotting the open end. The plastic bag containing wet linens should then be
placed in an approved laundry bag and closed before transporting to the proper designated
area.
? DO NOT OVERFILL BAGS more than 2/3 of capacity as overfilled bags tend to rupture if
they are dropped.
5. Review of the CDC and Centers for Medicare and Medicaid (CMS) recommendations, August,
2010, showed the following:
-Blood contamination is often evident on glucometers even if one cannot see it;
-Facilities must use an EPA-registered disinfectant to clean glucometers;
-Rubbing alcohol is not an effective disinfectant against [MEDICAL CONDITION] and should
not be used;
-It is important to use a glucose monitoring device designed for institutional use that
can be disinfected frequently;
-The manufacturer’s instructions should say which cleaning solution a device can
withstand;
-If the manufacturer’s instructions do not specify steps for cleaning and disinfecting
between uses of glucose monitoring devices, the devices generally should not be shared
among residents according the CMS.
6. Review of Resident #11’s care plan dated 8/14/17 showed:
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
-Problem: Incontinent of bladder and bowel;
-Approach: Provide me with perineal care after each incontinent episode.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument to be completed by the facility and dated 5/7/18 showed the following:
-Severely impaired cognition;
-Total dependence of two staff for toilet use and total dependence of one staff for
personal hygiene;
-Always incontinent of bladder and bowel.
Observation on 8/10/18 at 3:47 P.M. showed the following:
-The resident lay in his/her bed;
-Certified Nurse Assistant (CNA) N and CNA O entered the resident’s room to perform
perineal care, un-taped the resident’s urine soiled incontinent brief and rolled the
resident to his/her left side;
-CNA N picked up a moistened wash cloth and reaching from behind, reached through the
resident’s legs (with surfaces of the cloth touching the inner thighs) to the front and
then pulled it back through. The CNA then repeated the same with a second cloth.
-CNA N tucked the soiled brief and then without washing hands or changing gloves tucked
the clean brief;
-CNA N without changing gloves or washing hands and CNA O rolled the resident to his/her
right side;
-CNA O pulled the urine soiled brief out from under the resident, and then pulled the
clean brief out, assisted the resident to his/her back and both CNAs fastened the brief
and covered the resident;
-CNA N without changing glove or washing hands exited the room carrying the bag of soiled
items, walked down the hall to the soiled utility, disposed of the bags and degloved;
-CNA N then walked to the shower room where he/she washed his/her hands.
During interview on 8/10/18 at 4:10 P.M., CNA N said hands should be washed after they
become soiled and gloves changed after perineal care. CNA O said hands should be washed
and gloves changed after perineal care and before touching clean items and before exiting
the room.
7. Review of Resident #19’s quarterly MDS dated [DATE] showed the following:
-Short and long term memory problem
-Required total assistance of two staff members with transfers;
-Required extensive assistance of two staff members with bed mobility and toileting;
-Required extensive assistance of one staff member with dressing and personal hygiene;
-Required an indwelling urinary catheter (a sterile tube place in the bladder to drain
urine) and was always incontinent of bowel.
Review of the resident’s care plan revised 5/31/18 showed the following:
-[DIAGNOSES REDACTED].
-The resident was incontinent of urine, required a urinary catheter and was at increased
risk of urinary tract infections and complications. Staff should provide catheter care
every shift and maintain a closed urinary catheter system using aseptic (clean) technique
when accessing the catheter;
-The resident was confused and required one or two staff members assistance with
Activities of Daily Living, transfers and incontinence care. Staff should provide total
assistance with ADLs; provide urinary catheter care every shift, and bowel incontinence
care as needed. Assist with ADLS and be clean, dry and well-groomed at all times.
Observation on 8/7/18 at 3:45 P.M. showed the following
-CNA U and CNA V completed Resident #10’s mechanical lift transfer to the wheelchair and
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
CNA V combed the resident’s hair;
-CNA U and CNA V without washing hands or applying gloves attached the mechanical lift
sling under Resident #19 to the mechanical lift. CNA U picked up the resident’s urinary
drainage bag containing urine and placed it on the mechanical lift bar while CNA V applied
the resident’s shoes;
-CNA U and CNA V without washing hands or applying gloves transferred the resident to the
wheelchair;
-CNA V without washing hands or applying gloves picked up the resident’s urinary catheter
bag containing urine and handed CNA U the bag;
-CNA U without washing hands or applying gloves placed the resident’s urinary drainage bag
containing urine in the privacy cloth bag under the resident’s wheelchair;
-CNA U and CNA V without washing hands or applying gloves lifted the resident with the
mechanical lift sling under the resident and repositioned the resident in the wheelchair;
-CNA U without washing hands adjusted the resident’s shirt and touched the resident’s
hair;
-CNA V without washing hands obtained washcloths from the clean linen cart in the hallway
and wet the washcloths at the resident’s room sink;
-CNA V without washing hands handed CNA U a wet washcloth;
-CNA U without washing hands washed the resident’s face and hands while CNA V without
washing hands washed Resident #10’s face;
-CNA V without washing hands opened the room door and pushed Resident #19’s wheelchair
into the hallway;
-CNA U without washing hands adjusted Resident #10’s hair, pushed the mechanical lift into
the hallway and pushed the soiled linen cart down the hallway.
Observation on 8/9/18 at 6:20 A.M. showed the following:
-Nursing Assistant (NA) R wore gloves and wiped feces from the resident’s buttocks;
-NA R without washing hands or changing gloves removed the resident’s gown and placed the
gown on the floor;
-NA R without washing hands or changing gloves dressed the resident and assisted with a
mechanical lift transfer to the wheelchair;
-NA R without washing hands, changed gloves and applied Resident #10’s (Resident #19’s
roommate) clean socks and pants, removed the gloves and without washing hands, obtained an
oxygen portable tank from the closet down the hall, opened a package of oxygen tubing and
attached the oxygen tubing to Resident #19’s oxygen concentrator.
During interview on 8/9/18 at 2:25 P.M. CNA U said the following:
-He/she should wash hands and change gloves every time he/she provided the residents
cares;
-He/she should change gloves and wash hands anytime the gloves were soiled and in between
the resident’s cares;
-He/she did not wash hands and change gloves while providing the residents cares and went
from one resident to another without washing hands.
During interview on 8/9/18 at 4:20 P.M. CNA V said he/she should wash hands and change
gloves after caring for every resident and when the gloves were soiled.
8. Review of Resident #10’s quarterly MDS dated [DATE] 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;
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