North Village Park
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
crutches because in the past residents used them as a weapon;-She told the staff member she would need
a referral to evaluate Resident #10;-There had been no referral for the resident received. During an
interview on 8/12/25 at 3:15 P.M. the Director of Nursing (DON) said the following:-Resident #10 had an order for non-weight bearing to his/her right foot on 7/9/25. She just saw the order yesterday (8/11/25) and added it to the resident's POS;-She expected nurses to call and report non-compliance for dressing changes or non-weight bearing status to the physician;-When residents returned from appointments it was
the responsibility of the receptionist to collect their paperwork and scan it. Then a copy is supposed to go to her, medical records, and the nurse;-It was the nurse's responsibility to enter any new order for residents
after an appointment;-She expected the nurse to complete the wound care for residents, and not to have
the residents complete it. During an interview on 8/13/25 at 11:31 A.M. the physician said the following:-He never received communication from the facility about Resident #10's dressing coming off in the night, that
the resident would remove the dressing for showers, and that the resident refused a wheelchair to be non-weight bearing;-He would expect the resident to use a walker, wheelchair or whatever Resident #10 would use to be offloading on his/her right foot;-He never received communication from the facility about Resident #9 not being compliant offloading his/her left foot, why the resident did not make it to scheduled appointments, and why dressing changes were not completed;-He would expect the nursing staff to provide all wound care and not allow Resident #9 to clean his/her own wound;-The residents should not be allowed to leave the facility without dressings covering their feet;-There had been times when the residents' arrived at their appointments without a dressing covering their wounds. Resident #9 came to a few appointments without shoes on;-When the facility did not follow his wound care orders, the residents were at risk for infection and amputation. 2583338
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Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
North Village Park
2041 Silva Lane Moberly, MO 65270
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0742
F 0742 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
mg at 7:00 A.M., 11:00 A.M., and 4:00 P.M.;-The resident refused to take melatonin 3 mg at 5:00 P.M.;-The resident refused to take quetiapine 50 mg at 5:00 P.M.;-The resident refused to take trazodone 50 mg at 5:00 P.M. There was no documentation in the resident's medical record the staff notified physician the resident refused medication. Review of the resident's progress note, dated 8/12/25 at 11:07 A.M., showed
the following:-The IDT met with the resident;-The resident expressed delusions. Review of the resident's MAR, dated 8/12/25, showed the following:-The resident refused to take aripiprazole 10 mg at 7:00 A.M.;-The resident refused to take buspirone 20 mg at 7:00 A.M., 11:00 A.M. Review of the resident's progress note, dated 8/12/25 at 2:50 P.M., showed the following:-The facility received notice the resident was accepted for an inpatient psychological evaluation;-Staff informed the resident and he/she immediately became aggressive. The resident was very delusional and talked in different voices;-The resident did finally agree to go to the hospital and left with a driver and two other staff members. During an interview on 8/12/25 at 9:34 A.M. Resident #4 said the following:-He/She and Resident #3 had each other by the shirt and swung at each other;-He/She hit Resident #3;-He/She did not have a problem with Resident #3, he/she just defended himself/herself. During an interview on 8/13/25 at 8:30 A.M. Nursing Assistant (NA)/Housekeeper I said the following:-Resident #3 has cussed NA I out and not let him/her clean Resident #3's room;-When Resident #3 did not take his/her medications, he/she yelled, cussed, would not let housekeeping clean his/her room and walked down the hallway and randomly hit others. During an
interview on 8/13/25 at 8:41 NA H said the following:-Resident #3 acted aggressive and snapped at the littlest of things on 8/4/25;-Resident #3 got upset when Resident #15 kept changing the channel on the TV;-Resident #14 stood up and took off his/her jacket and Resident #3 thought Resident #14 was going to hit him/her;-NA S walked Resident #14 to his/her room and Resident #3 followed but nothing happened between them;-Resident [TRUNCATED]
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
North Village Park
2041 Silva Lane Moberly, MO 65270
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Plan, dated 6/13/25, showed the following:-The resident had limited physical mobility related to his/her left foot amputation;-The resident had infection of the left foot related to gangrene (death of body tissue due to
a lack of blood flow or a serious bacterial infection)/sepsis;-The resident had actual impairment to his/her skin integrity of the left foot status post amputation;-No evidence of staff documentation related to the resident's right foot ulcer. Observation on 8/12/25 at 10:23 A.M. of wound care provided by Licensed Practical Nurse (LPN) A for Resident #10 showed the following:-LPN A entered Resident #10's room.
He/She did not wash his/her hands before he/she donned clean gloves;-LPN A placed wound supplies on top of the resident's bedspread without a clean barrier;-LPN A picked up scissors off the resident's bedspread and used them to cut Vaseline gauze (a fine mesh, absorbent gauze impregnated with white petrolatum) before applying it to the resident's wound on the resident's right foot;-LPN A did not wash his/her hands or change his/her gloves. He/She used dry gauze to wipe off the wound on the resident's left foot. During an interview on 8/12/25 at 10:23 A.M. LPN A said the following:-Enhanced Barrier Precautions signage was posted because of Resident #10's foot wounds;-He/She did not wear a gown when he/she provided wound care for the resident;-The facility did not always provide gowns for the staff;-LPN A should have worn a gown to provide wound care;-LPN A looked through the personal Protective Equipment (PPE) cart outside the resident's room and said there were no gowns in the cart;-LPN A pulled out a white package on the cart and said they were XXL gowns and too large for him/her. During an interview on 8/12/25 at 3:15 P.M. the Director of Nursing (DON) said the following:-Resident #9 should have EBP signage and PPE outside his/her door/room;-Resident #9 moved rooms and the sign must not have gone with him/her;-Staff should wear gowns and gloves when providing wound care to residents;-She expected
the nurse to complete the wound care for residents, and not have the resident complete.2583338
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NORTH VILLAGE PARK in MOBERLY, MO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MOBERLY, MO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NORTH VILLAGE PARK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.