Big Bend Woods Healthcare Center

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

his/her room was searched by the Administrator and DON from staff at the facility. During an interview on 9/10/25 at 1:20 P.M., the Administrator said she was informed by staff the resident had marijuana in his/her room. She and the DON searched the resident's room and found six bags of marijuana infused edibles and two vaporizer pens. She confiscated the items and called the resident's family member to pick them up. The resident was in the hospital when the room was searched. The Administrator could not recall if she obtained permission from the resident's representative prior to searching the room but did document the occurrence.

During an interview on 9/12/25 at approximately 9:30 A.M., the Administrator said she did not obtain permission from the resident or representative prior to searching his/her room. The items were returned to

the family, and 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

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Bend Woods Healthcare Center

110 Highland Avenue Valley Park, MO 63088

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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator.

Observation on 9/10/25 at 7:53 A.M., showed a mini refrigerator in the resident's room with no temperature log on or nearby the refrigerator. The refrigerator contained V8 juices and other beverages. During an

interview on 9/10/25 at 9:38 A.M., the resident did not understand questions regarding the temperature of his/her personal refrigerator. 7. Review of Resident #17's MDS, dated [DATE REDACTED], showed:-Cognitive impairment;-No behaviors;-Utilizes a manual wheelchair;-Diagnoses included diabetes, dementia, anxiety and traumatic brain injury. Observation and interview on 9/8/25 at 9:07 A.M., showed the resident sat in his/her wheelchair in his/her room. A mini refrigerator sat on a stand in the resident's room. No temperature log was on or near the refrigerator. The resident said he/she used the refrigerator regularly and keeps milk

in there. Observations on 9/9/25 at 10:59 A.M., 9/10/25 at 7:45 A.M. and 9/11/25 at 8:56 A.M., showed a mini refrigerator in the resident's room. No temperature log was observed on or near the refrigerator. 8.

Review of Resident #4's quarterly MDS, dated [DATE REDACTED], showed:-Cognitively intact;-Diagnoses included high cholesterol, dementia, and 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 REDACTED], 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

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Bend Woods Healthcare Center

110 Highland Avenue Valley Park, MO 63088

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unless the resident is diabetic or on a blood thinner, in which case nail care must be done by the nurse. The ADON expected staff to check resident's feet and fingernails when providing daily care. If they observe a resident's toenail is purple or dark in color, they should notify the nurse and the nurse would notify the physician. If a resident uses their hands while eating, staff should help the resident wipe their hands when

they are finished eating, and get underneath the resident's fingernails. If a resident's clothing becomes soiled, staff should clean up the resident and change their clothing. During an interview on 9/12/25 at 9:15 A.M., the ADON and the Nurse Manager said they expected staff to check incontinent residents at least every two hours and as needed. Nail care and trimming can be provided by nursing staff during the resident's bath. The resident's feet can also be moisturized at any time but usually with bathing. They would expect staff to know which residents were on their assignments. 7. During an interview on 9/12/25 at 10:30 A.M., the Administrator said she expects staff to check on incontinent residents every two hours to ensure their needs are met. Nursing staff are expected to provide fingernail care and foot care when needed. Staff should apply lotion to a resident's feet if they are noted to be dry and flaking. If staff observe a resident's toenail is discolored, they should report it to the nurse. CNAs can trim a resident's toenails unless they are diabetic. Nurses trim toenails for diabetic residents. If a resident's toenails are too thick and cannot be trimmed by the nurse, the resident should be referred to podiatry. If a resident eats with their hands, staff are expected to wash the resident's hands and get underneath their fingernails, if tolerated. If a resident's clothing becomes soiled, staff are expected to provide care to 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

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

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Big Bend Woods Healthcare Center

110 Highland Avenue Valley Park, MO 63088

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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

expects staff to follow physician orders and accurately give residents their medications in their entirety. 2.

Review of Resident #86's medical record showed diagnoses that included cognitive communication deficit and diabetes.Review of the resident's physician order sheets (POS), dated, September 2025, showed:-An order dated, 5/22/25, Novolog FlexPen subcutaneous (fatty layer of the skin) solution pen injector 100 units per milliliter (ml), inject 14 units subcutaneously with meals;-An order dated, 5/22/25, Novolog FlexPen subcutaneous solution pen injector 100 units per ml, inject per sliding scale (a measurement of blood sugar), if blood sugar is: 151-200 inject 2 units; 201-250 inject 4 units; 251-300 inject 6 units; 301-350 inject 8 units; 351-400 inject 10 units.Observation on 9/9/25 at 11:34 A.M., showed Licensed Practical Nurse (LPN) J took the resident's blood sugar and the resident's blood sugar showed 173. LPN dialed the resident's Novolog FlexPen to 16 units, entered the resident's room and administered the Novolog insulin to

the back of the resident's left arm. LPN J did not prime the Novolog FlexPen prior to administering the insulin. 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

Event ID:

Facility ID:

If continuation sheet