Inspection Reports for
Big Bend Woods Healthcare Center
110 HIGHLAND AVE, VALLEY PARK, MO, 63088-1422
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
67% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 90
Deficiencies: 9
Date: Sep 12, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with federal regulations regarding resident rights, care, environment, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity during room searches, inadequate call light accessibility and functionality, poor environmental cleanliness, failure to provide adequate personal care and hygiene, medication administration errors, improper preparation of pureed foods, infection control lapses in laundry and catheter care, and failure to maintain a working call system with audible alerts.
Deficiencies (9)
Failure to protect a resident's right to dignity by searching a resident's room without consent and removing personal belongings.
Failure to ensure call light was within reach for a resident dependent on staff for toileting and personal hygiene.
Failure to maintain a safe, clean, comfortable, and homelike environment including unclean bathrooms, soiled wheelchairs, unclean resident rooms, and lack of temperature logs on personal refrigerators.
Failure to ensure professional standards in medication administration including lack of blood pressure parameters, incomplete nutritional supplement orders, and failure to apply tubi-grips as ordered.
Failure to provide adequate personal care and hygiene assistance to residents including untrimmed nails, soiled clothing, and inadequate bathing and grooming.
Medication error rate exceeded 5%, including failure to administer several medications and improper insulin pen priming.
Failure to ensure pureed foods were palatable and had appropriate texture, with pureed items being lumpy and gritty.
Infection control failures including mixing of clean and dirty laundry areas, trash transported through clean linen areas, and catheter bags dragging on the floor.
Call light system on 100 hall did not produce audible alerts, impairing staff response to resident calls.
Report Facts
Sample size: 20
Census: 90
Medication error rate: 16.13
Number of medication opportunities observed: 31
Number of medication errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT I | Certified Medication Technician | Named in medication administration errors and blood pressure monitoring |
| LPN K | Licensed Practical Nurse | Interviewed about medication administration and insulin pen priming |
| RN A | Registered Nurse | Interviewed about medication administration and resident care |
| Administrator | Interviewed regarding policies, call light system, and overall facility expectations | |
| ADON | Assistant Director of Nursing | Interviewed about medication parameters, resident care, and facility expectations |
| Nurse Manager | Interviewed about call light system, medication administration, and resident care | |
| CNA B | Certified Nursing Assistant | Interviewed about call light system and resident care |
| CNA C | Certified Nurse Aide | Interviewed about resident care and call light system |
| Dietary Manager | Interviewed about preparation of pureed foods | |
| LPN J | Licensed Practical Nurse | Observed administering insulin without priming pen |
| LPN Q | Licensed Practical Nurse | Observed with resident catheter bag dragging on floor |
| LPN S | Licensed Practical Nurse | Observed resident catheter bag on floor |
| Maintenance Director | Interviewed about laundry and call light system |
Inspection Report
Routine
Census: 90
Deficiencies: 4
Date: Sep 12, 2025
Visit Reason
The inspection was a routine regulatory visit to assess compliance with resident rights, safety, hygiene, and medication administration standards at Big Bend Woods Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding room searches, inadequate cleaning and maintenance of resident environments, insufficient personal care and hygiene assistance, and medication administration errors including failure to administer prescribed medications and improper insulin pen use.
Deficiencies (4)
Failure to protect a resident's right to be treated with dignity and respect when staff entered the resident's room without consent and removed personal belongings.
Failure to provide a safe, clean, comfortable and homelike environment including unclean bathrooms, wheelchairs, resident rooms, and lack of temperature logs on personal refrigerators.
Failure to provide adequate personal care and assistance with activities of daily living, resulting in poor hygiene, long fingernails with debris, dry flaky feet, and untrimmed toenails for several residents.
Medication error rate exceeded 5%, including failure to administer prescribed medications and failure to prime insulin FlexPens prior to administration.
Report Facts
Census: 90
Sample size: 20
Medication error rate: 16.13
Medication opportunities observed: 31
Medication errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Involved in room search without resident consent and discussed policy expectations | |
| Director of Nursing | DON | Accompanied Administrator during room search and involved in findings |
| Assistant Director of Nursing | ADON | Interviewed regarding cleaning expectations, medication administration, and resident care |
| Nurse Manager | Interviewed regarding cleaning expectations, medication administration, and resident care | |
| Certified Medication Technician I | CMT I | Observed and interviewed regarding medication administration errors |
| Licensed Practical Nurse K | LPN | Interviewed regarding medication administration policies |
| Licensed Practical Nurse J | LPN | Observed administering insulin without priming the pen |
| Registered Nurse A | RN | Interviewed regarding insulin pen priming procedures |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding two residents engaging in sexual activity, one of whom had cognitive impairment, which raised concerns about consent and abuse.
Complaint Details
The complaint investigation found that Resident #1, with severe cognitive impairment, was involved in sexual activity with Resident #2. Resident #1 could not consent to sexual activity. The facility staff were unaware of the sexual involvement until observed by nursing staff. The facility responded with staff training and care plan updates. Resident #2 was discharged shortly after the incident.
Findings
The facility failed to ensure that two residents, including one with severe cognitive impairment, did not engage in sexual activity. The facility provided staff in-servicing on abuse and neglect policies and updated the care plan for the cognitively impaired resident. No injuries were noted, and the cognitively impaired resident could not consent to sexual activity.
Deficiencies (1)
Failure to protect residents from sexual abuse, including non-consensual sexual contact involving a resident with cognitive impairment.
Report Facts
Residents present: 88
Sample size: 4
Frequency of monitoring: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Reported observing sexual activity and escorted Resident #2 out of Resident #1's room |
| LPN B | Licensed Practical Nurse | Observed sexual activity and alerted LPN A; involved in escorting Resident #2 out |
| Social Service Director | Social Service Director | Interviewed regarding residents' relationship and cognitive status |
| Director of Nursing | Director of Nursing | Notified of incident, provided in-servicing, and commented on Resident #1's inability to consent |
Inspection Report
Plan of Correction
Census: 88
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Big Bend Woods Healthcare Center following a previous non-compliance related to abuse and neglect.
Findings
The facility failed to ensure two residents, one with cognitive impairment, did not engage in sexual activity, violating the freedom from abuse and neglect regulation. The deficiency was corrected on 2025-03-11 with staff in-servicing and policy updates.
Deficiencies (1)
F 600 Freedom from Abuse and Neglect: The facility failed to prevent sexual activity between two residents, one cognitively impaired, violating abuse and neglect protections. The deficiency was corrected with staff training and care plan updates.
Report Facts
Census: 88
Sample size: 4
Inspection Report
Routine
Census: 86
Deficiencies: 18
Date: Feb 8, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident funds management, resident rights, privacy, environment, grievance procedures, abuse prevention, care and services, infection control, and other aspects of facility operations.
Findings
The facility had multiple deficiencies including failure to follow up on outstanding resident trust fund checks, incomplete third party liability forms for deceased residents, failure to post survey results accessibly, privacy violations during care, unclean resident rooms, inadequate grievance handling and notification, failure to check nurse aide registry for all employees, failure to notify the ombudsman of resident transfers/discharges, failure to implement care plans for pressure ulcers and falls, failure to provide personal care and bathing as scheduled, failure to provide appropriate restorative services, unsafe wheelchair propulsion and transfers, improper medication storage, lack of qualified dietary director, serving food at unsafe temperatures, improper hand hygiene during food service, incomplete medical documentation, and infection control lapses during perineal care.
Deficiencies (18)
Failure to follow up on outstanding resident trust fund checks dating back to 2020.
Failure to complete third party liability forms within 30 days for deceased residents with funds.
Failure to post survey results in a place readily accessible to residents and families.
Failure to protect resident privacy during personal care when exposed to roommate.
Failure to maintain clean, odor-free resident rooms with sticky floors and stains.
Failure to make prompt efforts to resolve grievances and failure to notify residents of grievance rights and grievance official contact information.
Failure to check nurse aide registry for federal indicator for all employees prior to hire.
Failure to notify State Long-Term Care Ombudsman of resident transfers and discharges monthly.
Failure to implement interventions for pressure ulcer and fall risk; failure to administer ordered antibiotic.
Failure to provide personal care and bathing assistance as scheduled and according to resident preferences.
Failure to provide ongoing restorative therapy program and failure to apply splints as ordered.
Failure to ensure resident feet are properly positioned on wheelchair footrests and failure to use gait belt during transfers.
Failure to ensure medication cart not in use was locked and medications properly labeled.
Failure to employ a qualified Director of Dietary when consultant RD not full-time.
Failure to serve food at safe and palatable temperatures; multiple residents reported cold food.
Failure to follow proper hand hygiene and infection control practices during food service and resident care; resident used cup to scoop ice from communal ice bucket.
Failure to maintain complete and accurate medical records including medication administration and skin assessments.
Failure to adhere to infection control principles during perineal care and wound dressing application.
Report Facts
Residents affected: 86
Outstanding checks: 17
Medication doses undocumented: 34
Missed catheter care entries: 11
Missed colostomy care entries: 11
Missed showers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN M | Licensed Practical Nurse | Noted missing antibiotic order entry and documented rash |
| CNA G | Certified Nursing Assistant | Observed improper glove use during perineal care |
| Clinical Supervisor C | Clinical Supervisor | Observed improper hand hygiene during meal service |
| Wound Nurse | Wound Nurse | Observed improper wound dressing handling |
| Administrator | Facility Administrator | Provided expectations on grievance, restorative program, and food temperature |
| DON | Director of Nursing | Provided expectations on transfers, restorative program, infection control, and grievance |
| Activity Director | Activity Director | Reported resident complaints about noise in dining room and bingo location |
| Dietary Director | Dietary Director | Noted lack of certification and improper hand hygiene by staff |
| Staffing Coordinator | Staffing Coordinator | Reported no restorative program and lack of CNA report sheets |
| OT E | Occupational Therapist | Discussed splint use and restorative therapy needs |
| RN D | Registered Nurse | Reported resident complaints about bingo noise and splint use |
| CMT H | Certified Medication Technician | Reported resident complaints about bingo noise and splint use |
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure staff followed policy on providing basic life support and CPR, specifically related to a resident found unresponsive with clinical signs of irreversible death.
Complaint Details
The complaint investigation found that staff did not check the resident's code status or initiate CPR despite the resident having a physician order for CPR. Staff relied on visual assessment and did not follow the facility's policy to initiate CPR until code status was confirmed. The Director of Nurses and Administrator confirmed expectations for CPR initiation and policy guidance were not met.
Findings
The facility failed to provide adequate guidance in their CPR policy for staff when a resident shows obvious clinical signs of irreversible death and failed to ensure staff were CPR-certified. Staff did not check the resident's code status or initiate CPR when a resident was found deceased, contrary to policy requirements.
Deficiencies (2)
Failure to ensure policy provided guidance for staff regarding CPR when a resident shows clinical signs of irreversible death and to ensure CPR-certified staff provide CPR.
Failure to follow facility policy to correctly identify a resident's code status and initiate CPR when a resident was found unresponsive with clinical signs of irreversible death.
Report Facts
Sample size: 13
Census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Documented resident condition and involved in assessment when resident was found deceased |
| LPN B | Licensed Practical Nurse | Assessed resident and agreed resident was deceased |
| CNA C | Certified Nurse Aide | Reported resident was unresponsive and involved in initial discovery |
| CMT E | Certified Medication Technician | Present during resident assessment, unsure if CPR was performed |
| Director of Nurses | Director of Nurses | Provided interview confirming policy expectations and clinical judgment |
| Administrator | Administrator | Provided interview confirming expectations for CPR and policy guidance |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Date: Jul 29, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to maintain resident room temperatures at or below 81 degrees Fahrenheit, impacting the comfort and safety of residents during a prolonged air conditioning unit repair.
Complaint Details
The complaint investigation found substantiated issues with room temperatures exceeding safe levels due to a broken air conditioning unit. Residents and staff reported excessive heat, with one staff member hospitalized for suspected heat stroke. The facility had been using portable air conditioners and fans as temporary relief while repairs were underway.
Findings
The facility failed to maintain safe and comfortable temperatures in resident rooms for four residents due to a broken air conditioning unit under repair for about one month. Temperatures in affected rooms exceeded the policy range, reaching up to 85.5 degrees Fahrenheit, causing discomfort and some residents experiencing heat-related symptoms. The facility used portable air conditioners and fans as temporary measures while repairs were ongoing.
Deficiencies (1)
Failed to maintain temperatures in resident rooms at or below 81 degrees Fahrenheit, impacting resident comfort and safety.
Report Facts
Census: 87
Temperature readings: 85.5
Refrigerant charged: 84
Fuse amperage: 200
Repair dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Family Member A | Reported resident discomfort due to heat in room | |
| Registered Nurse A | Registered Nurse | Reported extreme heat in building and planned to use personal fan |
| Certified Nurse Aide B | Certified Nurse Aide | Reported heat conditions and personal hospitalization due to suspected heat stroke |
| Certified Nurse Aide C | Certified Nurse Aide | Reported heat conditions in facility |
| Maintenance D | Provided information on room temperature monitoring and air conditioner repair status | |
| Housekeeper E | Housekeeper | Reported air conditioner had been out for a while |
| Certified Medication Technician F | Certified Medication Technician | Reported staff comments comparing temperature conditions between units |
| Administrator | Administrator | Provided information on air conditioner repair status and resident room temperature management |
Inspection Report
Routine
Census: 86
Deficiencies: 6
Date: Jul 21, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate orders and monitoring for PICC line and blood glucose, failure to prevent pressure ulcers, inadequate pain management with medication delays, improper narcotic count procedures, and lapses in infection control practices during personal care.
Deficiencies (6)
Failure to treat residents with dignity and respect, including not providing clean clothing after incontinence care and rude communication to residents.
Failure to obtain and follow orders for PICC line care and blood glucose monitoring, and failure to notify physician of out-of-range blood glucose results.
Failure to prevent development of additional pressure ulcers and failure to provide appropriate pressure ulcer care including use of low air loss mattress and repositioning.
Failure to provide scheduled pain medication consistently, resulting in resident being out of pain medication for over a week.
Failure to conduct narcotic counts properly at each shift change, including missing signatures and total counts, and allowing staff to sign after shift ended.
Failure to follow infection control protocols during personal care, including improper glove use, failure to perform hand hygiene, and use of soiled linens and blankets.
Report Facts
Residents affected: 17
Census: 86
Deficiency counts: 6
Blood glucose results above 400: 6
Pressure ulcer measurements: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse I | Named in infection control deficiency for improper glove use and hand hygiene | |
| CNA G | Certified Nursing Assistant | Named in dignity and respect deficiency for telling resident to wait their turn |
| Nurse B | Licensed Practical Nurse | Named in blood glucose and PICC line care deficiency |
| CNA E | Certified Nurse Aide | Named in dignity and respect deficiency for inappropriate comments to resident |
| CMT C | Certified Medication Technician | Named in pain management deficiency for reporting resident out of pain medication |
| Nurse A | Named in pain management deficiency for observations about resident pain behavior | |
| CNA A | Certified Nursing Assistant | Named in pressure ulcer deficiency for reporting skin impairments and resident pain |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including dignity, infection control, narcotic counts, and pain management |
| Administrator | Facility Administrator | Named in multiple deficiencies including dignity, infection control, narcotic counts, and pain management |
Inspection Report
Routine
Census: 91
Deficiencies: 12
Date: May 11, 2023
Visit Reason
Routine inspection of Big Bend Woods Healthcare Center to assess compliance with regulatory requirements including resident rights, call light response, resident self-determination, environment, medication administration, pressure ulcer care, falls prevention, catheter care, feeding tube care, pain management, controlled substance storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, delayed response to call lights, failure to honor resident self-determination, inadequate environmental cleanliness and maintenance, incomplete medication and treatment administration, failure to provide appropriate pressure ulcer care, incomplete fall documentation and reporting, inadequate catheter and feeding tube care, inconsistent pain management, failure to properly count controlled substances, and lapses in infection control protocols during personal care.
Deficiencies (12)
Resident left exposed during personal care and staff discussed roommate's hygiene in presence of roommate.
Staff failed to answer call lights for extended periods causing resident distress.
Failure to promote and facilitate resident self-determination through support of resident choice.
Failure to maintain clean, comfortable, home-like environment including food debris on floor, unclean commode, unwashed bedsheets, and leaking ceilings.
Failure to ensure appropriate treatment and monitoring of PICC line and blood glucose monitoring orders; failure to notify physician of out of range blood glucose results.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing; multiple missed treatments documented.
Failure to follow fall program policy including failure to document and report falls and lack of staff knowledge on fall procedures.
Failure to provide appropriate catheter care and prevent urinary tract infections for residents with suprapubic catheters; one resident developed UTI.
Failure to follow physician orders regarding feeding tube administration including lack of documentation of tube placement checks, feeding administration, and flushing.
Failure to provide safe and appropriate pain management; missed doses and unavailable medications documented.
Failure to count controlled substances at each shift change as required by policy.
Failure to follow infection control protocols during personal care including failure to change gloves between dirty and clean tasks and failure to perform hand hygiene.
Report Facts
Sample size: 16
Census: 91
Medication administration missed: 30
Fall risk evaluation dates missing signatures: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in findings related to resident exposure during care and infection control lapses |
| Director of Nursing | Director of Nursing | Provided interviews on expectations for care, fall reporting, infection control, and medication administration |
| LPN B | Licensed Practical Nurse | Interviewed regarding PICC line and blood glucose monitoring |
| CNA L | Certified Nursing Assistant | Reported on falls during overnight shift |
| RN M | Registered Nurse | Interviewed about awareness of falls |
| LPN N | Licensed Practical Nurse | Interviewed about feeding tube care and orders |
| Pharmacy Technician | Pharmacy Technician | Interviewed about medication refill and prescription orders |
Inspection Report
Routine
Census: 75
Deficiencies: 19
Date: May 6, 2021
Visit Reason
Routine state inspection survey to assess compliance with healthcare regulations including resident care, safety, and facility operations.
Findings
The facility was cited for multiple deficiencies including failure to notify residents timely about account balances, inadequate security of resident funds, privacy violations during care, failure to maintain surety bond, inadequate grievance policy implementation, improper use and documentation of physical restraints, failure to investigate abuse allegations, failure to maintain medical equipment, medication administration errors, inadequate wound care and pressure ulcer management, failure to monitor and report catheter issues, improper medication storage and documentation, insufficient staff training, incomplete bed rail assessments, and delayed response to resident call lights.
Deficiencies (19)
F 0569: Facility failed to notify residents or responsible parties timely when resident accounts were within the $200 SSI limit, affecting 7 residents.
F 0570: Facility failed to maintain a surety bond for resident trust funds at one and one half times the average monthly balance.
F 0583: Facility failed to ensure privacy during care for two residents by not closing doors or pulling privacy curtains.
F 0585: Facility failed to establish and implement an effective grievance policy and failed to respond promptly to grievances.
F 0604: Facility failed to ensure ongoing assessment and documentation of physical restraints for one resident using a seat belt as a restraint.
F 0607: Facility failed to thoroughly investigate abuse allegations and failed to ensure new employees did not have resident contact before background checks were completed.
F 0658: Facility failed to ensure one resident's BiPap machine was in working order and failed to document physician notification and catheter removal for another resident.
F 0677: Facility failed to provide adequate perineal care, maintain trimmed toenails, and ensure timely showers for sampled residents.
F 0684: Facility failed to notify physician timely of critical lab results, failed to administer antibiotics as ordered, failed to maintain PICC line per orders, and failed to administer medications per physician orders.
F 0686: Facility failed to provide appropriate pressure ulcer care, failed to complete weekly skin assessments, failed to ensure treatments were applied as ordered, and failed to provide adequate staff training on wound care.
F 0689: Facility failed to ensure timely response to resident call lights for multiple residents, with some residents reporting waits up to three hours.
F 0690: Facility failed to ensure tube feeding was administered as ordered for one resident, with the feeding pump turned off for extended periods without documentation.
F 0692: Facility failed to ensure nutritional supplements were provided as ordered and failed to monitor resident food intake adequately.
F 0698: Facility failed to ensure medications and biologicals were properly labeled and stored securely, failed to maintain accurate controlled substance counts, and failed to ensure medication administration was properly documented.
F 0755: Facility failed to maintain medication error rate below 5%, with an 8.66% error rate observed in medication administration for sampled residents.
F 0761: Facility failed to ensure medication administration was performed by authorized staff and failed to secure electronic medical records with individual user credentials.
F 0867: Facility failed to develop and implement an effective QAPI plan to address identified quality deficiencies related to pressure ulcer care and treatment.
F 0909: Facility failed to ensure routine inspection and maintenance of bed frames, mattresses, and bed rails to prevent entrapment hazards for residents using side rails.
F 0919: Facility failed to ensure resident medical records were accurate, confidential, and secure, including failure to prevent unauthorized access and falsification of electronic medical records.
Report Facts
Medication error rate: 8.66
Residents affected by SSI notification failure: 7
Residents with census during inspection: 75
Pressure ulcer residents identified: 13
Pressure ulcer residents sampled: 8
Controlled substance shift counts missing: 46
Certified nurse aides with less than 12 hours annual training: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Registered Nurse | Administered medications under another nurse's electronic signature |
| Nurse TT | Registered Nurse | Failed to document resident fall and skin tear, and failed to notify oncoming shift |
| CMT C | Certified Medication Technician | Responsible for CNA training, medication administration, and reported lack of training and documentation |
| DON | Director of Nursing | Reported multiple facility deficiencies including medication administration, wound care, and staff training |
| Administrator | Facility Administrator | Reported on QAPI meetings and facility improvement plans |
| ADON | Assistant Director of Nursing | Reported on wound care and dialysis communication deficiencies |
| Nurse I | Registered Nurse | Observed catheter issues and reported lack of physician orders |
| Nurse A | Registered Nurse | Observed medication administration errors and improper medication storage |
| CNA Y | Certified Nursing Assistant | Reported dressing issues and wound care concerns |
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