Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Valley View Health & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure residents were treated with dignity and respect, as evidenced by the behavior of a CMT who was reported to be rude, rough, and condescending during care. Residents expressed feelings of anger and worthlessness, and staff corroborated these complaints. Despite previous write-ups and expectations for respectful treatment, the facility did not adequately address the ongoing issues with the CMT's behavior.
The facility failed to provide adequate assistance with ADLs for two residents, resulting in poor personal hygiene and grooming. One resident, with impaired mobility and cognitive issues, was found with long, dirty fingernails and soiled clothing, while another resident with Parkinson's disease had similar nail issues. Staff interviews revealed frequent refusals of care by the residents, and a lack of documented attempts to provide necessary hygiene care.
A resident in a LTC facility repeatedly obtained and used smoking materials inside the facility, despite being educated on the smoking policy. The resident was observed smoking in his room while wearing oxygen, posing a safety hazard. The facility failed to update the resident's care plan or smoking assessment in a timely manner, and did not implement new interventions for increased supervision, contributing to the ongoing issue.
A resident with a history of transverse myelitis, diabetes, and peripheral vascular disease experienced worsening pressure ulcers due to inadequate documentation and monitoring by the facility. The care plan was not updated to reflect the presence of pressure ulcers, and the facility failed to communicate changes to the resident's physician or NP. The decision to not use a low-air loss mattress, as recommended, was made without consulting the physician, contributing to the deficiency.
The facility failed to use proper transfer techniques for residents requiring assistance, leading to accidents and injuries. A resident sustained a fracture due to a fall during a transfer without a gait belt or proper footwear. Another resident, with a history of stroke, was transferred without a gait belt, feeling unsteady and fearful of falling. A third resident, with severe cognitive impairment, was also transferred without a gait belt, contrary to facility policy.
The facility failed to maintain safe and sanitary food handling practices, with staff observed not following proper hand hygiene, gloving, and hair restraint protocols. Food storage was inadequate, with items not properly sealed, labeled, or dated. Clean dishes were improperly stored, and surface sanitation was insufficient, leading to potential cross-contamination.
A long-term care facility failed to adhere to infection prevention protocols, with staff neglecting proper hand hygiene and Enhanced Barrier Precautions (EBP) during resident care. Observations revealed improper handling of soiled items, inadequate use of personal protective equipment, and incorrect storage of medical devices, increasing infection risks.
The facility failed to provide necessary oral hygiene care for two residents who required assistance. One resident, with multiple mental health diagnoses, did not receive regular teeth brushing or denture cleaning, leading to feelings of neglect. Another resident, with functional quadriplegia, had significant dental issues and reported a lack of staff assistance with oral care. Interviews with facility leadership revealed an expectation for oral care assistance that was not being met.
The facility failed to ensure the Medical Director or a designee attended the QAPI meetings quarterly, as required by their QAPI Plan. The QAA committee, responsible for addressing quality deficiencies, lacked the Medical Director's participation in meetings held in July, August, and September 2024. The Administrator confirmed the absence and noted that the Medical Director was not reminded monthly, nor was a designee sent.
Two residents in a long-term care facility were neglected in their ADL care. One resident, with a history of stroke, was left in bed with a swollen arm, unable to reach the call light or drinks, and was found with dried feces on the skin. Another resident, admitted with morbid obesity, experienced prolonged incontinence due to slow staff response, with soiled linens left unchanged for over seven hours. Staff interviews revealed a failure to adhere to care policies, resulting in these deficiencies.
A resident with an indwelling urinary catheter and a history of UTIs did not receive proper catheter care, leading to a deficiency. Observations showed feces around the catheter insertion site and improper cleaning by staff, despite facility policies requiring clean techniques to prevent infections. Interviews revealed staff did not follow care plans, contributing to the resident's risk of infection.
A facility failed to ensure proper hand hygiene and glove use by staff during care for a resident with a history of stroke and other conditions. Staff were observed using feces-soiled gloves to touch various items and apply skin barrier cream without washing hands or changing gloves, contrary to the facility's infection control policy. Interviews confirmed the staff's failure to follow proper procedures, leading to a deficiency in infection prevention and control.
A CMT at the facility removed and ingested hydrocodone-acetaminophen pills from the narcotic medication cards of three residents. The discrepancies were discovered during a random spot check by the consulting pharmacist, who confronted the CMT. The CMT admitted to consuming the medications and was subsequently terminated. The local police department was notified, and a complete count of all narcotics revealed no further discrepancies.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as evidenced by the behavior of Certified Medication Technician (CMT) F. Resident #10 reported that CMT F was rude and rough during care, which hurt the resident's feelings and made them feel angry. The resident expressed fear of retaliation if they reported CMT F's behavior. Resident #9 also experienced rough and forceful care from CMT F, who dismissed the resident's complaints with inappropriate language, making the resident feel worthless. Resident #13 described CMT F as condescending and authoritative, which provoked feelings of anger. The facility's policies on Resident Rights and Conduct and Behavior, which emphasize treating residents with kindness, respect, and dignity, were not adhered to by CMT F. Interviews with other staff members, including a Certified Nurse Assistant (CNA) and the Director of Nursing (DON), corroborated the residents' complaints. The CNA reported that many residents found CMT F's tone harsh and upsetting, and that complaints had been made to charge nurses without any action being taken. The DON acknowledged receiving complaints about CMT F's lack of a gentle approach. The Administrator confirmed that CMT F had been previously written up for not providing good customer service and reiterated the expectation that all residents should be treated with dignity and respect. Despite these expectations, the facility's failure to address the ongoing complaints about CMT F's behavior resulted in a deficiency in maintaining the residents' rights to a dignified existence and respectful treatment.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #1, who had an ADL self-care performance deficit related to impaired mobility and cognitive impairment, was observed with long, uneven fingernails and brown debris under them. The resident's room and clothing were also soiled with fecal matter, and there was a strong odor of urine and feces. Despite being cognitively intact according to the Minimum Data Set (MDS), the resident often refused showers and nail care, and staff did not document any attempts to provide nail care during showers. Resident #7, who had a self-care deficit related to Parkinson's disease and moderate cognitive impairment, was also found with long, uneven nails and brown debris under them. The resident required substantial assistance with bathing and personal hygiene but often refused care, allowing only certain staff to trim their nails. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were unaware of the resident's nail condition, indicating a lack of consistent care and monitoring. Interviews with staff revealed that both residents frequently refused showers and nail care, and staff felt limited in their ability to provide care due to these refusals. The facility's policy required staff to attempt different approaches if a resident resisted care, but there was no documentation of such attempts. The Administrator acknowledged the issue, noting that Resident #1's odor was a common complaint among other residents and that showers should be provided at least twice a week or per resident preference.
Inadequate Supervision of Resident Smoking in Facility
Penalty
Summary
The facility failed to provide adequate supervision and protective oversight for a resident who repeatedly obtained and used smoking materials within the facility, despite being educated on the smoking policy. The resident, who was cognitively intact and had no visual or dexterity deficits, was observed smoking in his room while wearing oxygen, which posed a significant safety hazard. Despite multiple incidents of the resident being found with cigarettes and lighters, the facility did not update the resident's care plan or smoking assessment in a timely manner to reflect these occurrences or implement new interventions for increased supervision. The resident's care plan initially included education on smoking risks and the requirement to smoke only in designated areas without oxygen. However, the resident was found smoking in various locations within the facility, including his room and the dining room, and admitted to propping doors open to smoke unsupervised. Staff repeatedly educated the resident on the smoking policy, but there was no documentation of any other interventions being put in place until much later. The facility's smoking policy required assessments and individualized approaches for residents who smoke, but these were not consistently updated or enforced. Interviews with staff revealed that the resident had a history of being homeless and possibly picking up cigarette butts, which may have contributed to the difficulty in managing his smoking behavior. Despite the implementation of a new smoking policy requiring supervision, the resident continued to smoke inside the facility, and staff did not conduct room searches or provide increased supervision as needed. The facility's failure to adequately supervise the resident and update his care plan and smoking assessment contributed to the ongoing safety hazard.
Failure to Document and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to adequately document and monitor the pressure ulcers of a resident, leading to a worsening of the condition. The resident, who had a history of transverse myelitis, diabetes mellitus, and peripheral vascular disease, was readmitted to the facility with pressure ulcers on the buttocks. The facility's staff did not update the care plan to reflect the presence of these pressure ulcers, nor did they document any goals or interventions to address them. Despite the resident's condition worsening, there was no evidence that the staff communicated these changes to the resident's physician or primary care nurse practitioner (NP). The facility's wound care nurse, who was not wound care certified, was responsible for the resident's wound care. The nurse documented the condition of the pressure ulcers in weekly assessments but failed to notify the primary care NP of the changes in the resident's condition. The resident's care plan was not updated to include the use of a low-air loss mattress, as recommended in the hospital discharge orders, because the interdisciplinary team decided to focus on the resident's goal of returning home and working on slide board transfers. This decision was made without consulting the resident's physician or primary care NP. The primary care NP did not evaluate the pressure ulcers during visits and relied on the wound care nurse for updates. The NP assumed that other specialists were managing the resident's pressure ulcers, but there was no documentation to support this. The facility's Director of Nursing and Administrator were unaware of the worsening condition of the pressure ulcers until the resident was discharged to the hospital, where the ulcers were assessed as stage IV. The facility's failure to follow its wound care policy and communicate effectively with the primary care team contributed to the deficiency.
Failure to Use Proper Transfer Techniques
Penalty
Summary
The facility failed to ensure safe transfer techniques for residents requiring assistance, leading to accidents and injuries. Resident #133, who had intact cognition and required partial to moderate assistance with transfers, was not provided with proper footwear or a gait belt during a transfer to a bedside commode. This resulted in the resident slipping on a wet floor and sustaining a displaced fracture of the tibia/fibula. The CNA involved did not use a gait belt, as the resident had previously indicated they could transfer independently, and did not notice the wet floor prior to the transfer. Resident #30, who had a history of stroke and required assistance due to weakness, was also not provided with a gait belt during transfers. The resident expressed feeling unsteady and fearful of falling when assisted by CNA C, who lifted the resident under the arm instead of using a gait belt. The care plan indicated the need for a mechanical lift, but this was not followed, and the resident was barefoot during the transfer. Resident #21, with severe cognitive impairment and hemiplegia following a stroke, was assisted by CNA C without the use of a gait belt, despite the resident's care plan indicating the need for maximum assistance with transfers. The resident was able to stand briefly, but the lack of a gait belt was contrary to facility policy and staff training. Interviews with staff and administration confirmed the expectation that gait belts should be used for all standby transfers, but this was not consistently practiced.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner, as evidenced by multiple observations of improper hand hygiene, gloving techniques, and hair restraint usage by the dietary staff. The Dietary Manager and other staff members were observed handling food and kitchen equipment without changing gloves or washing hands between tasks, leading to potential cross-contamination. Additionally, staff were seen touching food contact surfaces with bare hands and using soiled gloves to handle ready-to-eat food items. Further observations revealed that hair restraints were not properly used, with staff members having exposed hair while preparing food. This lack of adherence to hygiene protocols was compounded by inadequate surface sanitation practices. Cleaning cloths were not properly sanitized or stored in sanitizing solutions, and spills were wiped with dry cloths that were not subsequently sanitized, increasing the risk of contamination. The facility also failed to adhere to proper food storage protocols. Opened food items were not securely sealed, labeled, or dated, and some items were stored contrary to manufacturer's instructions. Additionally, clean dishes were not stored inverted or covered, and some were found with visible debris or damage. These deficiencies in food handling and storage practices highlight significant lapses in maintaining a sanitary environment for food preparation and service.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, affecting several residents. Staff did not perform appropriate hand hygiene during personal care for two residents, and failed to utilize Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube. Additionally, a resident's urinary catheter drainage bag was improperly stored on the floor, and another resident's wound vac was also placed on the floor, increasing the risk of infection. These actions were observed during routine care and were not in compliance with the facility's policies. In one instance, a Certified Nurse Assistant (CNA) was observed cleaning a resident's perineal area, then handling soiled items and touching clean surfaces without washing hands or using hand sanitizer. The CNA admitted to not following proper hand hygiene protocols. Another CNA failed to wear a gown while providing care to a resident on EBP, despite signage indicating the requirement. The CNA also did not change gloves between dirty and clean tasks, and did not wash hands after removing gloves. Furthermore, a Certified Medication Technician (CMT) was observed administering medications without performing hand hygiene before and after the process. The CMT handled medications with bare hands and did not sanitize hands between residents. Interviews with staff, including the Infection Preventionist and Director of Nursing, confirmed that these practices were not in line with expected standards, highlighting a systemic issue in adherence to infection control protocols.
Failure to Provide Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate oral hygiene care for two residents, Resident #41 and Resident #48, who required assistance with oral care. Resident #41, diagnosed with schizophrenia, depression, bipolar disorder, and PTSD, had a care plan indicating a need for extensive assistance with personal/oral hygiene. However, observations revealed that the resident's teeth were not brushed regularly, and the resident's upper dentures were not cleaned. Interviews with the resident and a CNA indicated a lack of awareness and action regarding the resident's oral care needs, with the resident expressing feelings of neglect and uncleanliness. Resident #48, with functional quadriplegia and poor dentition, was also dependent on staff for oral hygiene. Observations showed significant dental issues, including cavities and black stubs for teeth, with a white film and black spots on the lower teeth. The resident reported that staff did not assist with brushing teeth, leading to discomfort and a feeling of an unclean mouth. The care plan and Kardex did not specifically address the resident's oral hygiene needs, contributing to the oversight. Interviews with the Director of Nursing and the Administrator revealed an expectation for staff to assist with oral care every morning and after meals, which was not being met. The facility's policy on mouth care lacked specific instructions on the frequency of oral care, contributing to the deficiency in providing necessary oral hygiene assistance to the residents.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director or a designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis, as required. The facility's QAPI Plan, dated March 2020, outlined that the Quality Assessment and Assurance (QAA) committee was responsible for addressing quality deficiencies, analyzing problems, establishing corrective actions, and reporting findings. The QAA committee was supposed to include the Administrator, all department heads, the Medical Director, and a Pharmacist. However, a review of the QAA meeting attendance logs for July, August, and September 2024 showed no documentation of attendance by the Medical Director or a designee. During an interview, the Administrator confirmed that the Medical Director did not attend any of the QAA meetings and had not been reminded monthly about the meetings, nor had a designee been sent in their place.
Neglect in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate care for two residents who were dependent on staff for Activities of Daily Living (ADLs). Resident #2, who had a history of stroke and was receiving hospice care, was observed in a state of neglect. The resident was left in bed with a swollen, shiny, and taut right arm dangling off the side, unable to reach the call light or drinking cups. The resident's personal hygiene was neglected, as evidenced by matted hair, soiled gown, and dried feces on the skin. Staff failed to reposition the resident, provide range of motion exercises, or offer fluids, despite the resident's inability to perform these tasks independently. Resident #7, who was admitted with morbid obesity and lymphedema, experienced a similar lack of care. The resident reported that staff were slow to respond to call lights, resulting in prolonged periods of incontinence. The resident's bed linens were not changed for over seven hours, and staff covered the soiled bed with a towel instead of providing proper incontinence care. Observations confirmed the presence of a large urine stain and a strong odor, indicating neglect in maintaining the resident's hygiene and comfort. Interviews with staff, including the Director of Nursing and the Administrator, revealed a failure to adhere to the facility's policies and care plans. Staff admitted to being busy and not checking on residents as frequently as required. The facility's policy mandated that residents should be checked at least every two hours, kept clean and dry, and have access to fluids and call lights. However, these standards were not met, leading to the deficiencies observed in the care of Residents #2 and #7.
Failure to Provide Proper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate urinary incontinence and catheter care for a resident with an indwelling urinary catheter and a history of urinary tract infections (UTIs). The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, was observed with brown-colored urine in the catheter tubing and feces around the catheter insertion site. The facility's policy required staff to maintain clean technique and cleanse the catheter and surrounding area to prevent infections, but this was not followed. During an observation, a CNA and a Nurse Assistant were seen removing the resident's gown and noting soft, loose feces between the resident's legs, perineal skin folds, and around the catheter insertion site. Dried feces were also noted between the resident's upper thighs. The CNA wiped the resident's thighs and perineal skin folds with wet wipes but did not clean around the catheter insertion site or tubing. The resident's buttocks, hips, and perineal skin folds were soiled with feces, and the CNA repeatedly wiped these areas with wet wipes, causing the resident to yell out in pain. The staff did not cleanse the urinary catheter insertion site, leaving feces near it. Interviews with the CNA and the Director of Nursing revealed that the CNA had not checked on the resident since earlier in the morning and admitted to not providing proper perineal care or cleansing the catheter tubing and insertion site. The Director of Nursing stated that staff should follow care plans and provide necessary care to keep residents clean and prevent infections. The resident had a history of UTIs and was treated with antibiotics, highlighting the importance of proper catheter care to prevent further infections.
Inadequate Hand Hygiene and Glove Use During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove use by nursing staff during personal care for a resident, leading to a deficiency in infection prevention and control. The facility's policy on hand hygiene, dated August 2019, emphasized the importance of handwashing as the primary means to prevent the spread of infections. It required staff to wash hands with soap and water when visibly soiled and to use alcohol-based hand rubs before and after direct contact with residents, among other situations. The policy also stated that gloves should be changed when soiled and that hand hygiene should be performed after removing gloves. During an observation, a Certified Nurse Assistant (CNA) and a Nurse Assistant (NA) were seen applying gloves without washing their hands and proceeding to provide care to a resident with soiled gloves. The resident, who had a history of stroke with paralysis, aphasia, and other conditions, was dependent on staff for personal care. The CNA used the same feces-soiled gloves to touch various items in the resident's room, including the bed controller and linens, and applied skin barrier cream to the resident's skin without changing gloves or washing hands. This was contrary to the facility's hand hygiene policy and posed a risk of infection. Interviews with the CNA and the Director of Nursing (DON) confirmed that the staff did not follow proper hand hygiene and glove-changing procedures. The CNA admitted to not washing hands or changing gloves correctly and acknowledged the importance of handwashing in preventing infections. The DON reiterated that staff should follow care plans and hand hygiene policies to keep residents clean and prevent the spread of infections. The facility's failure to adhere to its own infection control policies resulted in a deficiency noted by surveyors.
Misappropriation of Narcotic Pain Medication by CMT
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for three residents. Certified Medication Technician (CMT) A removed and ingested hydrocodone-acetaminophen pills from the narcotic medication cards of three residents while on duty. This was discovered during a random spot check by the consulting pharmacist, who found discrepancies in the narcotic counts and confronted CMT A, who admitted to consuming the medications. Resident #1 had moderately impaired cognition and took scheduled pain medication for chronic conditions, including chronic kidney disease and chronic venous hypertension. The narcotic count sheet showed a discrepancy of one pill missing, which CMT A admitted to ingesting. Resident #2, with severely impaired cognition and frequent pain, had a discrepancy of two pills missing from their narcotic count sheet, which CMT A also admitted to ingesting. Resident #3, with severely impaired cognition and multiple chronic conditions, had a discrepancy of one pill missing, which CMT A admitted to ingesting as well. The pharmacist and the Director of Nursing (DON) were informed of the discrepancies, and CMT A admitted to taking the medications. The DON immediately took CMT A to the administrator's office, where CMT A was terminated for misappropriation of resident narcotic medications. The local police department was notified, and a complete count of all narcotics was conducted, revealing no further discrepancies.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Moberly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Moberly | 1.7 mi | ★★★★★ | 5 | 1 |
| North Village Park | 2 mi | ★★★★★ | 52 | 3 |
| Heritage Hall Nursing Center | 20 mi | ★★★★★ | 5 | 0 |
| Chariton Park Health Care Center | 21 mi | ★★★★★ | 7 | 1 |
| Monroe Manor | 22.7 mi | ★★★★★ | 0 | 0 |
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