North Village Park
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
around LPN E and grabbed Resident #2 by the hair and swung him/her down to the ground. During an
interview on 11/16/25, at 3:39 P.M. and 4:45 P.M. and 11/18/25 at 11:40 A.M., Resident #2 said the following:-Resident #3 attacked him/her because he/she thought Resident #2 took his/her $3.00;-LPN E got between the two of them and Resident #3 reached over LPN E to hit Resident #2, but LPN E blocked most of it;-Then Resident #3 reached around LPN E and pulled him/her by the hair to the ground;-The resident hit the floor really hard;-Resident #3 also hit him/her in the side and hit his/her hip which was now bruised;-His/Her ribs hurt, and he/she thought they were broken because Resident #3 hit him/her in the side. During an interview on 11/16/25, at 1:30 P.M., Resident #3 said the following:-He/She tried to hit Resident #2, but staff was in the way;-He/She grabbed Resident #2 by the hair and pulled the resident to
the floor; once Resident #2 was on the floor he/she struck the resident in the side;-He/She attacked Resident #2 because he/she thought Resident #2 stole his/her $3.00. Review of Resident #12's written statement, dated 11/14/25, showed he/she took Resident #3's $3.00. He/She didn't think Resident #3 would put hands on Resident #2. Observation on 11/16/25, at 3:39 P.M., showed Resident #2 with half dollar sized knot on the left temporal region of his/her forehead with purple spots in the center of the knot, yellow discoloration was present on his/her forehead from the knot down to his/her left eye. The resident's left eye is bruised dark purple on his/her eye lid from the edge of the eye lid to the eyebrow, and dark purple under
the residents left eye approximately 1.5 cm. Observation on 11/18/25, at 11:45 A.M., showed the resident's right hip with a large bruise with a dark purple oval area, surrounded by green and yellow discoloration. The area was the size of the resident's palm and oval in shape. No discoloration was noted on the resident's left ribs, but he/she said they were sore. 4. During an interview on 11/16/25, at 3:15 P.M. the Assistant Administrator (AADM) said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. This was witnessed by staff and an investigation was completed by himself and the Administrator.
During an interview on 11/17/25, at 10:16 A.M., and 11/18/25, at 11:30 A.M., the Administrator said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. This was witnessed by staff and an investigation was completed by himself and the Assistant Administrator. They did not think Resident #3 was truly trying to harm Resident #2. When Resident #3 pulled Resident #2 to the ground by his/her hair, Resident #3 could have hit Resident #2 in the face, but he/she restrained himself/herself.
Resident #3 could have hurt Resident #2 and struck him/her in the face, but he/she did not. Complaint #2669277
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
11/18/2025
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 F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
11/16/25, at 1:30 P.M., Resident #3 said the following:-He/She tried to hit Resident #2, but staff was in the way;-He/She grabbed Resident #2 by the hair and pulled the resident to the floor; once Resident #2 was on
the floor he/she struck the resident in the side;-He/She attacked Resident #2 because he/she thought Resident #2 stole his/her $3.00. Review of Resident #12's written statement, dated 11/14/25, showed he/she took Resident #3's $3.00. He/She didn't think Resident #3 would put hands on Resident #2.
Observation on 11/16/25, at 3:39 P.M., showed Resident #2 with half dollar sized knot on the left temporal region of his/her forehead with purple spots in the center of the knot, yellow discoloration was present on his/her forehead from the knot down to his/her left eye. The resident's left eye is bruised dark purple on his/her eye lid from the edge of the eye lid to the eyebrow, and dark purple under the residents left eye approximately 1.5 cm. Observation on 11/18/25, at 11:45 A.M., showed the resident's right hip with a large bruise with a dark purple oval area, surrounded by green and yellow discoloration. The area was the size of
the resident's palm and oval in shape. No discoloration was noted on the resident's left ribs, but he/she said
they were sore. 4. During an interview on 11/16/25, at 3:15 P.M. the Assistant Administrator (AADM) said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. It was witnessed by staff and an investigation was completed by himself and the Administrator. The incident with Resident #2 and Resident #3 was not reported to the state agency or law enforcement. Both he and the Administrator did not report because they determined it was not abuse. During an interview on 11/17/25, at 10:16 A.M., and 11//25, at A.M., the Administrator said Resident #3 grabbed Resident #2 by the hair and pulled Resident #2 to the ground. This was witnessed by staff and an investigation was completed by himself and
the Assistant Administrator. The facility did not report to the state agency or to law enforcement because
they did not think Resident #3 was trying to harm Resident #2. The one time Resident #3 tried to hit Resident #2 staff softened it; when Resident #3 pulled Resident #2 to the ground by his/her hair, Resident #3 could have hit Resident #2 in the face but restrained himself/herself so he and the AADM determined it was not abuse and did not have to be reported. Complaint #2669277
Event ID:
Facility ID:
If continuation sheet
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.