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Complaint Investigation

Big Bend Woods Healthcare Center

September 12, 2025 · Valley Park, MO · 110 Highland Avenue
Citations 4
CMS Rating 1/5
Beds 135
Provider ID 265130
Healthcare Facility
Big Bend Woods Healthcare Center
Valley Park, MO  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

BIG BEND WOODS HEALTHCARE CENTER in VALLEY PARK, MO — inspection on September 12, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0557
Resident Rights Deficiencies

the resident's family member to pick them up.

The resident was in the hospital when the room was

9/12/25 at approximately 9:30 A.M., the Administrator said she did not obtain permission from the

it was explained that the items were not permitted in the facility.

She expected the policies to be followed and resident consent prior to searching a resident's room. 14541571454156

265130 09/12/2025

Big Bend Woods Healthcare Center 110 Highland Avenue Valley Park, MO 63088

Review of Resident #4's quarterly MDS,

psychotic disorder.

Observation on 9/9/25 at 4:20 P.M., showed the resident had a personal mini refrigerator in the room. No temperature log sheet observed.

Observation and interview on 9/11/25 at 8:53 A.M., showed the resident's refrigerator did not have a temperature log sheet.

The resident said he/she had never seen any staff check the refrigerator.

The refrigerator contained some milk and juices.

The resident's roommate said staff were supposed to check the refrigerator's temperature daily, but nobody was doing it since the time he/she was moved to the room, which was approximately a year ago. 9.

Review of Resident #6's annual MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included diabetes, high cholesterol, high blood pressure, anxiety, depression and schizophrenia (a serious mental health condition that affects how people think, feel and behave).

Observation and interview on 9/11/25 at 8:58 A.M., showed the resident had a personal mini refrigerator in the room, by the sink. A blank temperature log sheet was taped on the side of the refrigerator.

The resident said he/she did not see any staff checking the refrigerator's temperature. He/She did not know what the piece of paper was for that was attached to the refrigerator.

The refrigerator contained milk, chocolate milk and bags of salads.

During an interview on 9/11/25 at 8:59 A.M., Housekeeping Aide H said they were not responsible for checking and logging temperature of the residents' personal refrigerators. He/She said the CNAs were responsible for that task.

During an interview on 9/11/25 at 9:04 A.M., CNA P said the Certified Medication Technicians (CMT) used to check the temperature of the residents' personal refrigerators.

He/She did not remember the last time they were being checked. He/She had not seen anyone check them lately.

During an interview on 9/11/25 at 2:23 P.M., Housekeeping Aide D said housekeeping staff does not touch or monitor the temperatures of personal refrigerators in resident rooms.

During an interview on 9/11/25 at 2:50 P.M., CNA B said dietary is the only department that checks the refrigerators in their kitchen. 10.

During an interview on 9/12/25 at 10:49 A.M., the Administrator said housekeeping is responsible for monitoring temperatures inside resident personal refrigerators.

She is unsure how often the refrigerator temperatures are checked.

They should be checked routinely, and housekeeping should have some system that should be in place.1454154

265130 09/12/2025

Big Bend Woods Healthcare Center 110 Highland Avenue Valley Park, MO 63088

resident's toenail is discolored, they should report it to the nurse. CNAs can trim a resident's toenails

eats with their hands, staff are expected to wash the resident's hands and get underneath their

the resident and change their clothes. Resident #71 has a behavior of refusing care and can become combative with staff.

When this occurs, she expected staff to redirect and reapproach later. CNAs can shave and trim a resident's beard.

Offering to shave or trim a resident's beard is part of a resident's daily care. 2567916

265130 09/12/2025

Big Bend Woods Healthcare Center 110 Highland Avenue Valley Park, MO 63088

During an interview on 9/11/25 at 8:56 A.M., Registered Nurse (RN) A said the insulin pens are to be primed with two units of insulin before administering the insulin to the resident every time.

Priming the pen removes any air bubbles and ensures the insulin dose more accurate.

During an interview on 9/11/25 at 10:40 A.M., LPN K said insulin FlexPens should only be primed when the pen is being used for the first time. LPN K was not aware if the insulin FlexPens should be primed with each use.

During an interview on 9/12/25 at 9:15 A.M., the Assistant Director of Nursing (ADON) and the Nurse Manager said the insulin FlexPens are expected to be primed by the nursing staff administering the medication with 2 units of insulin each time the FlexPen is being used. It ensures a more accurate dose by removing any air bubbles.

During an interview on 9/12/25 at 10:30 A.M., the Administrator said she would expect staff to prime insulin FlexPens prior to each use. 1454154

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 VALLEY PARK, 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 BIG BEND WOODS HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.