Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Big Bend Woods Healthcare Center during CMS and state inspections, most recent first.
Multiple residents experienced unclean living conditions, including a soiled bathroom left unaddressed after a plumbing issue, a dirty wheelchair with no cleaning schedule, and rooms with accumulated debris. Additionally, several residents with personal refrigerators did not have temperature logs or routine monitoring, despite storing perishable food items. Staff interviews revealed confusion and lack of clear responsibility for cleaning and temperature checks.
Surveyors identified a medication error rate of 16.13% after observing five errors in 31 opportunities, including a CMT failing to administer multiple prescribed medications to a resident with complex medical needs and an LPN not priming an insulin FlexPen before giving insulin to a diabetic resident. Documentation did not accurately reflect medication administration, and staff interviews revealed inconsistent understanding of proper procedures.
Laundry staff did not keep dirty and clean areas separated, as trash was moved through the folding area near clean linen carts and staff handled laundry between the washer, dryer, and sorting table without hand hygiene. A resident with a suprapubic catheter and wheelchair use also had the catheter bag observed on the floor or dragging on the floor multiple times, and an LPN noted it should not touch the floor.
A facility failed to ensure the 100 hall call light system worked properly, as room indicators and the nurse station panel lit up but the panel did not sound. Several alert and oriented residents said they waited long periods for staff response, and two said they could not hear the panel. CNAs reported the panel had not been audible for weeks, while the Nurse Manager, Maintenance Director, and Administrator each said they were unaware of the malfunction until survey observation and interview.
Staff entered a resident's room and removed personal belongings, including marijuana edibles and vape pens, without obtaining consent from the resident or their representative, despite facility policy requiring such consent. The resident was hospitalized at the time and later learned of the search and removal of items, expressing concern about the lack of notification or permission.
Several residents with cognitive and physical impairments did not receive necessary assistance with ADLs, resulting in long, dirty fingernails, untrimmed toenails, dry and flaky skin, and soiled clothing and bedding. Staff failed to follow care plans and facility protocols for hygiene, nail care, and incontinence checks, and did not consistently document or address refusals of care.
Call Light Not Kept Within Reach: A resident with dementia, stroke-related deficits, and total ADL dependence was observed in bed with the call light on the floor and later under the sheets at the foot of the bed, out of reach. Staff, including an RN, CNA, ADON, Nurse Manager, and Administrator, stated call lights are expected to always be within reach for all residents, regardless of cognition status.
The facility failed to follow physician orders for two residents receiving antihypertensive meds because BP hold parameters were missing, and staff held doses when low BP readings were observed. The facility also failed to specify the type and amount of a nutritional shake for a resident with malnutrition, and staff gave an estimated amount of house supplement. In addition, a resident with edema and cellulitis did not receive ordered tubi-grips on multiple observations, despite TAR documentation showing the treatment as given.
Pureed foods were served with poor texture and consistency for three residents. Staff prepared pureed ham, vegetables, and hamburgers using blending methods that resulted in grainy, lumpy, choppy, and runny mixtures; the DM tasted the foods and agreed they were not smooth, while the Administrator stated pureed items should have the consistency of pudding or mashed potatoes and should not be grainy or lumpy.
Two residents, one with severe cognitive impairment and one without, engaged in sexual activity without appropriate care plan documentation or staff awareness. Staff discovered the incident and intervened, but the lack of documentation and failure to recognize the risk led to a deficiency in protecting residents from non-consensual sexual contact.
Failure to Maintain Cleanliness and Environmental Safety for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for several residents, as evidenced by multiple observations and interviews. One resident with an indwelling urinary catheter and neurogenic bladder experienced a severe plumbing issue in their bathroom, resulting in brown water and fecal matter overflowing onto the floor. Despite the resident reporting the issue and being instructed by nursing staff to use alternative means to empty their catheter, the bathroom remained soiled and uncleaned overnight. Staff interviews confirmed that the bathroom was not cleaned promptly, and there was confusion regarding responsibility for cleaning and maintenance notification. Another resident, who uses a manual wheelchair and is cognitively intact, was observed multiple times sitting in a visibly dirty wheelchair with food crumbs, dust, and clumps of hair. The resident expressed dissatisfaction with the cleanliness of the wheelchair and reported never seeing staff clean it. Staff interviews revealed there was no established cleaning schedule for wheelchairs at the time, and responsibility for cleaning was unclear among staff members. Additional deficiencies were noted in the cleanliness of another resident's room, where trash and debris accumulated behind furniture and on the nightstand, contrary to the facility's housekeeping checklist. Furthermore, five residents with personal mini refrigerators in their rooms did not have temperature logs or evidence of routine temperature monitoring, despite storing perishable items such as milk and yogurt. Interviews with staff and residents indicated a lack of clarity and consistency regarding which department was responsible for monitoring refrigerator temperatures, and some residents reported that temperatures had not been checked for extended periods.
Medication Error Rate Exceeds Regulatory Threshold Due to Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, resulting in a 16.13% error rate based on 31 observed opportunities with five errors. During medication administration, a Certified Medication Technician (CMT) did not administer several prescribed medications, including escitalopram oxalate, celecoxib, aspirin, and Eliquis, to a resident with multiple diagnoses such as atrial fibrillation, major depressive disorder, heart failure, and neuropathy. Despite this, the Medication Administration Record (MAR) was documented as if the medications had been given. The CMT was unsure whether the medications were administered and stated that double-checking the MAR was part of their routine, but could not confirm the administration during the observed period. In another instance, a Licensed Practical Nurse (LPN) administered Novolog insulin using a FlexPen to a resident with diabetes and cognitive communication deficit but failed to prime the pen before injection. The resident's blood sugar was checked, and the insulin dose was dialed and administered, but the required priming step was omitted. Interviews revealed inconsistent knowledge among nursing staff regarding the need to prime insulin pens before each use, with some staff unaware of the correct procedure as outlined by the manufacturer and facility expectations. Facility leadership, including the Assistant Director of Nursing, Nurse Manager, and Administrator, confirmed that staff are expected to follow physician orders, utilize the five rights of medication administration, and adhere to proper procedures such as priming insulin pens. The observed failures to administer medications as ordered and to follow correct insulin administration protocols directly contributed to the elevated medication error rate identified during the survey.
Laundry Cross-Contamination and Catheter Bag on Floor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when laundry staff did not keep dirty and clean areas separated. During observation, trash was transported through the folding area and past clean linen carts, while laundry staff moved back and forth between the washer, dryer, and sorting table without hand hygiene. Clean linen carts were observed parked near cluttered and dirty items outside the maintenance room, and the floor in the area was sticky and dirty. The facility’s policy stated that clean linens are to be protected from dust and soiling, stored separately from soiled linens, and that hands are to be washed before handling clean linen during the laundering process. The facility also failed to keep Resident #80’s indwelling catheter bag off the floor. The resident had a suprapubic catheter, was cognitively impaired, used a wheelchair, and was dependent on staff for toileting hygiene. Observations showed the catheter bag lying on the floor beside the resident’s bed, hanging under the wheelchair and dragging on the floor while the resident was moved, and later touching the floor again at the nurse’s station. Staff observed the bag on the floor and acknowledged it should not touch the floor, but no repositioning was done at that time.
Call Light System Not Audible on 100 Hall
Penalty
Summary
The facility failed to ensure the call system on the 100 hall functioned properly, including the lights outside resident rooms and the audible signal at the nurse's station. The facility's Call Light policy, revised 8/1/18, stated that call lights should be answered promptly, but it did not include guidance for ensuring the call system remained functional. Survey observations showed multiple resident room call lights illuminated above doors and on the nurse's station panel without any audible alarm coming from the panel. During a group interview, three alert and oriented residents said they lived on the 100 hall and waited long periods for staff to respond to call lights. Two of those residents said they did not hear sounds from the call light panel at the nurse's station. Staff observations also confirmed the problem: when resident room call lights were activated, the indicator lights outside the rooms and on the nurse's station panel illuminated, but the panel did not make a sound. In one observation, a CNA entered a room and the outside light turned off, then turned back on when the CNA stood outside the door, and the CNA said he/she did not see it turn back on. Multiple CNAs stated the 100 hall call light panel had not been audible for weeks or did not make any sound at all, and one CNA said staff had to visually check the halls because the U-shaped layout prevented them from seeing all areas at once. The Nurse Manager said she was not aware the system was not functioning properly, and the Maintenance Director said he was also unaware that the panel was not audible and that one resident room call light was not working. The Administrator stated she learned that day that the 100 hall nurse's station panel was not making sound and expected staff to notify Maintenance, Administration, or nurse management if the system was not working.
Failure to Obtain Consent Before Room Search and Removal of Resident's Belongings
Penalty
Summary
Facility staff failed to protect a resident's right to dignity and respect when the Administrator and DON entered the resident's room and removed personal belongings without obtaining consent from the resident or the resident's representative. The facility's own policy requires that staff must not conduct searches of a resident's personal belongings unless the resident or their representative agrees to a voluntary search and understands the reason for it. In this case, the resident was hospitalized at the time of the search, and neither the resident nor their representative was contacted for permission prior to the search and removal of items. The incident involved a resident with diagnoses including diabetes, anxiety, and bipolar disorder, who was not exhibiting any behaviors at the time. Staff had been informed that the resident had marijuana in their room, prompting the Administrator and DON to search the room and confiscate six bags of marijuana-infused edibles and two vape pens, among other items. The resident later expressed concern about the search being conducted without their knowledge or consent, learning about it only after returning from the hospital. The Administrator confirmed that consent was not obtained prior to the search, which was in violation of facility policy.
Failure to Provide Adequate Assistance with ADLs and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to several residents who were unable to perform these tasks independently, resulting in inadequate personal hygiene. Multiple observations and interviews revealed that residents with significant cognitive and physical impairments did not receive timely or appropriate care as outlined in their individualized care plans. For example, one resident with moderate cognitive impairment, hemiplegia, and incontinence was repeatedly observed with long, dirty fingernails, extremely dry and flaky feet, and soiled bedding. Staff interviews confirmed that the resident had not been checked or cleaned according to the facility's protocol, and there was confusion among CNAs regarding assignment responsibilities. Another resident with moderate cognitive impairment and lower extremity impairment was observed with long, thick, and jagged toenails, including a purple discolored toenail, and dry, flaky feet. The resident expressed a desire for assistance with beard trimming and toenail care, which had not been provided. Staff interviews indicated that there was no documentation of the resident refusing care, and the nurse manager acknowledged that staff should have noticed and reported the discolored toenail and provided appropriate foot care and hygiene support. A third resident with severe cognitive impairment and hemiplegia was observed with long, dirty fingernails and soiled clothing after eating with their hands. Staff did not adequately clean the resident's hands or fingernails, and the resident reported dissatisfaction with their hygiene and appearance. Interviews with staff and management confirmed that the resident required maximum assistance with ADLs and that staff were expected to provide nail care, change soiled clothing, and assist with hand hygiene, but these tasks were not consistently performed. The care plan did not include specific interventions for refusals of care, and staff described challenges in providing care to residents who sometimes refused or became combative, but there was no evidence of consistent re-approach or alternative strategies documented.
Call Light Not Kept Within Reach
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met for one resident whose call light was repeatedly found out of reach while the resident lay in bed. The resident had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for toilet hygiene, personal hygiene, bathing, dressing, and transfers. Diagnoses included non-Alzheimer's dementia, diabetes, hemiplegia, stroke, and seizures. The resident's care plan addressed incontinence and extensive ADL and mobility dependence, but it did not address ensuring the call light was within reach. During observations, the resident's call light was seen on the floor under the bed and later under the sheets at the foot of the bed, both times out of reach. Facility staff interviewed stated that call lights are expected to be within reach for all residents and that staff should ensure the call light is near the resident before leaving the room. The ADON, Nurse Manager, and Administrator all stated they expected staff to ensure all residents always have their call light within reach, regardless of cognition status.
Failure to Follow Orders for BP Meds, Nutritional Supplement, and Tubi-Grips
Penalty
Summary
The facility failed to ensure services provided met professional standards by not including blood pressure parameters in physician orders for two residents receiving antihypertensive medications. One resident had diagnoses of stroke, hypertension, and hypertensive retinopathy and had orders for carvedilol 6.25 mg twice daily and lisinopril 10 mg each morning, but no hold parameters were listed. On observation, the resident’s blood pressure was 95/70 and the CMT stated the medications would be held and the nurse notified because the blood pressure was low. The MAR showed the morning doses were not administered, and there was no progress note documenting the low blood pressure. A second resident had diagnoses including atrial fibrillation, major depressive disorder, long-term anticoagulant use, heart failure, and neuropathy. The resident had an order for metoprolol succinate ER once daily for hypertension, but the order did not include blood pressure parameters. On observation, the resident’s blood pressure was 114/42 and pulse was 61. The CMT stated the nurse would be notified and the blood pressure medication held because the blood pressure was too low. The MAR documented the morning medication as not given due to vital signs outside of parameters, and there was no progress note related to the low blood pressure. The facility also failed to ensure a nutritional supplement order included the specific type and amount to be given for one resident with protein malnutrition, anorexia, and muscle weakness. The physician order stated only "nutritional shake, twice a day as a supplement" without identifying the supplement type or volume. During observation, the CMT gave approximately 60 mL of ReadyCare house supplement and stated there was no type or amount in the order, so a small amount was given because the resident normally would not drink it. Staff interviews confirmed the order should have specified the supplement type and amount. In addition, the facility failed to apply ordered tubi-grips for one resident with edema, cellulitis of the right lower limb, and heart failure. The resident had an order for tubi-grips to both lower extremities in the morning and off at night for bilateral lower extremity swelling. Multiple observations over several days showed the resident without tubi-grips on the lower legs, including times when the right lower leg was red, swollen, and had scabbed areas. The resident stated the compression socks were supposed to be applied daily and that staff had not put them on. Staff interviews indicated the resident did not receive the tubi-grips on those days, although the TAR documented them as administered.
Pureed Foods Served Grainy and Lumpy
Penalty
Summary
The facility failed to ensure adequate nutritive value, taste, and texture for pureed foods for three residents who ate pureed meals. During observation of the lunch meal, the Dietary Manager prepared pureed ham by blending three 4-ounce slices of ham with eight ounces of ham juice and one slice of bread for three residents. After tasting it, the texture was noted to be lumpy and gritty, and the Dietary Manager agreed it was grainy and lumpy, although she stated pureed foods should have the consistency of pudding or mashed potatoes. She then covered the ham with foil to serve. Later that day, the Dietary Manager prepared pureed mixed vegetables for three residents by blending four 4-ounce servings of vegetables with two and a half slices of bread and four ounces of vegetable juice. The mixture appeared lumpy and runny, tasted bland, and pieces of carrot were not blended to a mashed potato or pudding-like substance. The Dietary Manager agreed it was gritty and lumpy and covered it with foil to serve. During the dinner meal, another staff member prepared pureed hamburgers for three residents using ground beef, bread, and beef broth. The mixture remained grainy and choppy after repeated blending, and the Dietary Manager agreed it was grainy and said, "It could not be helped." The facility's pureed food guidelines stated the expected ingredients and blending process for pureed entrees and vegetables, and the Administrator stated pureed foods should have the consistency of pudding or mashed potatoes and should not be grainy or lumpy.
Failure to Prevent Sexual Activity Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to protect two residents from engaging in sexual activity, one of whom had severe cognitive impairment and was therefore unable to consent. The incident involved a resident with no cognitive impairment and another resident with severe cognitive impairment, as documented in their Minimum Data Set (MDS) assessments. Both residents' care plans lacked documentation regarding sexual behavior or expression, despite the facility's policy requiring such documentation when relevant. On the day of the incident, staff observed one resident receiving oral sex from another resident in a resident's room. Nursing staff intervened, escorted the resident out, and notified facility leadership. Interviews with staff and the Social Service Director confirmed that the cognitively impaired resident was not considered able to consent to sexual activity, and that staff were unaware of any sexual relationship between the two residents prior to the event. The facility's policies on abuse, neglect, and sexual expression outline the need to protect residents from non-consensual sexual contact and to ensure care plans address sexual expression when appropriate. However, these policies were not followed in this case, as there was no care plan documentation or staff awareness regarding the potential for sexual activity between the residents, leading to a failure to prevent the incident.
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What surveyors actually found near you
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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.
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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Valley Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden View Care Center At Dougherty Ferry | 0.9 mi | ★★★★★ | 0 | 0 |
| Lutheran Senior Services At Meramec Bluffs | 2.5 mi | ★★★★★ | 2 | 0 |
| Manchester Rehab And Healthcare Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Quarters At Des Peres, The | 3.3 mi | ★★★★★ | 8 | 0 |
| Aberdeen Heights | 3.7 mi | ★★★★★ | 1 | 0 |
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