Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
resident room doors, walls and floors in good repair on the 200 Hall. The census was 97.
Observations of the 200 Hall on all days of the survey, 2/22/18 through 2/23/18 and
2/26/18 through 2/28/18, showed the following:
-In room [ROOM NUMBER]:
-A crack at the seam of the wall and ceiling above the second resident bed measured
approximately 18 inches by 1 inch;
-Near the same area, a large brownish water stain on the ceiling measured approximately
18 inches by 24 inches, with paint peeled off the ceiling and an unfinished unpainted
area;
-Large drip-like stains down the wall under the cracked ceiling;
-In the middle of the same wall, a cable box hung off the wall;
-An approximate 4 inch by 2 inch rectangular hole in the wall to the right of the
bathroom, with exposed dry wall;
-An unfinished and unpainted area and no cove base under the sink;
-In room [ROOM NUMBER]:
-A large brownish water stain on the ceiling in the center of the room;
-Near the large water stain, an approximate 24 inch by 36 inch unfinished and unpainted
area on the ceiling;
-A large rectangular unfinished and unpainted area with an exposed white surface, to the
left of the door, near a newly installed light fixture;
-In room [ROOM NUMBER], a large rectangular unfinished and unpainted area with an exposed
white surface to the right of the door, near a newly installed light fixture;
-In room [ROOM NUMBER]:
-A large rectangular unfinished and unpainted area with an exposed white surface to the
right of the door, near a newly installed light fixture;
-A large area by the second bed with exposed dry wall;
-Approximately 3 feet of paint chipped off the wall in the corner near the vanity;
-A large unfinished, unpainted area with an exposed white surface under the sink;
-The closet door by the first bed with multiple areas of spackle;
-In room [ROOM NUMBER]:
-Numerous black horizontal scratches near the bottom of the interior of the restroom
door;
-A large rectangular unfinished and unpainted area with an exposed white surface to the
left of the door, near a newly installed light fixture;
-Paint peeled off the wall by the soap dispenser near the sink;
-In room [ROOM NUMBER]:
-A large rectangular unfinished and unpainted area with an exposed white surface to the
right of the door, near a newly installed light fixture;
-An approximate 11 inch by 17 inch area of paint peeled off at the corner of the wall to
the left of the vanity;
-An unfinished area under the sink, with exposed spackle;
-A cable box hanging off the wall;
-Eight holes in the wall near the cove base, each approximately the size of a pencil
eraser;
-Multiple water stains on the ceiling over the second bed;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 1)
-Multiple dents in the wall, with exposed dry wall over the bed rail of the second bed;
-In room [ROOM NUMBER]:
-Two black zip ties protruding out of the wall near the cove base to the left of the
entrance to the room;
-Paint chipped off both corners at the vanity;
-Multiple horizontal scratches covered the lower 3 feet of the bathroom door;
-In rooms [ROOM NUMBERS], large rectangular unfinished and unpainted areas with exposed
white surfaces near newly installed light fixtures;
-In room [ROOM NUMBER]:
-Multiple black horizontal scratches on the lower 8 inches of the room door;
-A large rectangular hole cut out in the exterior wall of the closet for the first bed,
near a newly installed light fixture;
-The left top drawer missing from the vanity/dresser;
-In room [ROOM NUMBER]:
-The wall leading to the bathroom with multiple dents and areas of chipped paint, with
exposed dry wall;
-Multiple horizontal scratches towards the bottom of the interior of the restroom door;
-In rooms [ROOM NUMBERS]:
-Inside the room doors, large rectangular unfinished and unpainted areas with exposed
white surfaces inside the doors near newly installed light fixtures;
-Multiple areas over the beds with paint peeled off the wall and exposed dry wall;
-In the therapy room:
-Four chipped floor tiles with missing pieces;
-An area of peeled paint measured approximately 4 inches by 2 inches on the wall behind
the fire extinguisher;
-In room [ROOM NUMBER]:
-A large square unfinished and unpainted area with an exposed white surface to the right
of the door near a newly installed light fixture;
-Several horizontal scratches on the bottom of the exterior of the restroom door;
-In room [ROOM NUMBER]:
-Inside the door, a large rectangular unfinished and unpainted area, with an exposed
white surface to the right of the door near a newly installed light fixture;
-Multiple horizontal black scratches on the bottom of the restroom door.
During an interview on 2/27/18 at 12:39 P.M., Housekeeper I said he/she received training
to notify the maintenance director if something needed to be repaired. The maintenance
director kept a log of what needed to be fixed.
During an interview on 2/28/18 at 8:50 A.M., the maintenance director said staff fill out
work orders available at every nurses station. He picks them up daily. Administration also
does daily rounds to look at resident rooms and identify any issues. This information is
then relayed to him. He also does daily rounds. The van driver also does weekly rounds and
helps with some of the needed repairs. The maintenance director said he finally had some
help but it had just been him for a long time.
Review of the provided work orders, showed the following:
-A work order, dated 4/26/17, for a wheel chair repair;
-A work order, dated 9/14/17, for clogged toilet;
-A work order, dated 10/24/17, for clogged toilet;
-No documentation of any issues for (YEAR).
During an interview on 2/28/18 at 9:30 A.M., the administrator said he does morning rounds
on a daily basis. The maintenance director and van driver also do rounds and have their
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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

(continued… from page 2)
own assessment of what needs to be repaired. He is aware of the water damage in room [ROOM
NUMBER]. The roofers were supposed to begin repairs earlier in the week, but did not show
up.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain blood
pressure as ordered, obtain daily weights and fax them to the physician weekly, clarify
incomplete orders with the physician, obtain laboratory tests and ensure an accurate
narcotic count for four of 20 sampled residents (Resident #96, #74, #198 and #38). The
census was 97.
1. Review of Resident #96’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/23/18, showed the following:
-Extensive assistance required for most activities of daily living (ADLs);
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Review of the resident’s electronic Medication Administration Record [REDACTED].M., 4:00
P.M. and 9:00 P.M. On 26 out of 66 opportunities in February, the MAR indicated[REDACTED].
During an interview 2/28/18 at 9:25 A.M., the Director of Nursing (DON) said she expected
all physician’s orders [REDACTED].
Review of the resident’s weights and vitals summary, provided by the Education coordinator
and printed from the computer program, showed between 2/7/18 and 2/27/18, staff did not
record his/her blood pressure three times daily on any of those days. The resident’s blood
pressure was not recorded at all on four of those days, recorded only once on 11 days and
recorded twice on five days.
2. Review of Resident #74’s significant change MDS, dated [DATE], showed the following:
-Brief interview for mental status (BIMS, a screening tool used to assess cognitive
impairment) score of three out of 15, which showed severe impairment;
-Limited assistance required for personal hygiene;
-Occasionally incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the current POS, showed the following:
-An order, dated 8/10/17, to administer med pass (fortified nutritional snack) after
meals. The order did not include the amount to administer;
-An order, dated 1/18/18, to administer med pass twice a day (BID). The order did not
include the amount to administer;
-An order, dated 2/1/18, to obtain a complete blood count (CBC, a blood test used to
evaluate overall health and detect a wide range of disorders, including [MEDICAL
CONDITION], infection and [MEDICAL CONDITION]), a comprehensive metabolic panel (CMP-a
blood test that gives doctors information about the body’s fluid balance, levels of
electrolytes and how well the kidneys and liver are working) and a [MEDICAL
CONDITION]-stimulating hormone (TSH) test (measures TSH level, which is produced by the
pituitary gland. TSH stimulates the [MEDICAL CONDITION] to release the hormones

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)[MEDICATION NAME] (T4) and triiodothyronine (T3) into the blood).
Review of the treatment administration records (TARs), from September, (YEAR) through
February, (YEAR), showed no documentation regarding med pass administration.
Review of the MARs, from September, (YEAR) through February, (YEAR), showed no
documentation regarding med pass administration.
Review of the complete electronic chart and paper chart, showed no results of blood tests
completed on 2/1/18 or through the month of February.
During an interview on 2/28/18 at 9:30 A.M., the DON and the ADON said when a second order
is written concerning the same medication or treatment, then it is the nurse’s
responsibility to discontinue the previous order. Med pass is ordered by the amount of
cubic centimeters (cc) to be administered and the nurse would be responsible for obtaining
clarification with the physician. All blood work results are kept in the paper chart after
reviewed by the physician and after looking for the blood work ordered on [DATE], they
were unable to locate any results.
3. Review of Resident #198’s admission MDS, dated [DATE], showed the following:
-Extensive assistance needed for dressing, toileting and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) (YEAR), showed the following:
-An order, dated 1/22/18, to weigh him/her daily and fax the weight log weekly on Mondays
to the physician, related to heart failure;
-An order, dated 1/22/18, to fax weight log weekly to the physician, in the morning every
Monday, related to heart failure.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed the following:
-An order to weigh daily and fax the log weekly on Mondays related to heart failure. Staff
did not document a weight on 2/14/18 through 2/16/18, 2/18/18, 2/19/18, 2/21/18 through
2/24/18 and 2/26/18;
-An order to fax weight log weekly every Monday morning related to heart failure. Staff
left Monday 2/19/18 and 2/26/18, blank with no documentation of faxed weekly log.
During an interview on 2/28/18 at 9:25 A.M., the DON said she expected all physician’s
orders [REDACTED]. RTA H is trying to get them done now. The resident’s daily weights and
documentation of weekly faxes to the physician were requested, but not provided, as late
as 3:00 P.M. on 2/28/18.
4. Review of Resident #38’s annual MDS, dated [DATE], showed the following:
-BIMS score of three, which showed severe impairment;
-[DIAGNOSES REDACTED].
-Received hospice services.
Review of the individual resident narcotic record, dated 3/19/17, showed the following:
-One 30 milliliter (ml) bottle of [MEDICATION NAME] (narcotic [MEDICATION NAME]), 20
milligrams (mg)/ml, administer 0.25 ml under the tongue every two hours as needed for
pain;
-On 3/29/17 the nurse administered 0.25 ml, leaving 29.75 ml;
-On 3/30/17 the nurse administered 0.25 ml. leaving 29.5 ml;
-No further administrations recorded and on 5/10/17, the count read 26 ml.;
-On 9/24/17 the nurse administered 0.25 ml. leaving 25.75 ml.
-No further administrations recorded and on 10/8/17 the count read 22 ml with the word
‘corrected’ written beside the number 22;
-An undated corrected count of 21 ml;
-No further administrations recorded and on 12/4/17 at 6:00 P.M., the count read 17 ml.;
-On 12/27/17 at 2:00 P.M., the DON and ADON counted the medication and recorded 22 ml
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
remained in the bottle.
During an interview on 2/28/18 at 9:00 A.M. the DON and ADON said the bottles of[MEDICATION NAME] hospice provides are more difficult to read than the bottles from their
pharmacy and staff have a very hard time reading the bottles. They both recently counted
the [MEDICATION NAME] to provide an accurate count, and have inserviced the nurses to draw
the medication out of the bottle with a syringe to obtain an accurate count and then
replace it in the bottle. They said the medication is not counted on a daily basis, only
when a dose is administered.
Observation of the [MEDICATION NAME] bottle on 2/28/18 showed approximately 22 ml in the
bottle. The measurement guide on the side of the bottle marks every five milliliters,
rather than every milliliter.
5. Review of the narcotic count book located on the 100 hall on 2/27/18 at 9:00 A.M.,
showed one sheet of paper at the front of the book, dated 2/2/18 through 2/26/18, that
contained resident names, names of narcotics and other medications that are required to be
stored under lock and key, nurses signatures and the number of medication cards.
During an interview on 2/27/18 at 9:00 A.M., Licensed Practical Nurse (LPN) G said the
pharmacy delivers different cards of medications for resident’s use and if the medication
is required to be secured behind lock and key, the nurse has to sign it in. He/she said
all of the cards are counted at the end of the shift and all are kept in the locked
cabinet. When a new card arrives for the resident the nurse adds the number of the cards
to the count and if a medication is discontinued, or a resident is discharged , that card
is deducted from the count.
Further review of the form, showed the following:
-On 2/14/18, a nurse accepted a card of [MEDICATION NAME] (used to treat anxiety) which
brought the count of cards to 38;
-On 2/16/18 at 6:00 A.M., staff drew a line through the form and the number of cards
remained 38;
-On 2/19/18 at 4:00 P.M., staff removed a card of [MEDICATION NAME] (narcotic [MEDICATION
NAME]) and the count read 36. Staff provided no documentation as to why the count went to
36 instead of 37.
During an interview on 2/28/18 at 9:30 A.M., the DON and ADON said they had no idea why
the count went to 36 instead of 37. They believed a nurse had removed a card to return to
the pharmacy and believed the nurse forgot to record it.
F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to summarize the stay for one of
the two discharge records reviewed. The staff did not write a discharge note or indicate
what information they provided to the resident and their family. (Resident #99) The census
was 97.
Review of Resident #99’s electronic record, showed an admission date of [DATE], for
rehabilitation under Medicare.
Review of the admission Minimum Data Set (MDS) a federally mandated assessment instrument
dated 12/1/17, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-A Brief Interview of Mental Status (BIMS, a brief screener of cognitive impairment) score
of 14, a score of 13-15, indicates cognitively intact;
-Supervision of one staff for transfers;
-Limited assistance of one staff for dressing;
-Set up help for eating;
-Extensive assistance of one staff for bathing;
-Occasionally incontinent of bowel and bladder.
Review of the (MONTH) (YEAR), physician order [REDACTED].>-A discharge order dated
12/21/17, to home with home health and physical and occupational therapy and all
medications;
-Medications included insulin, aspirin, [MEDICATION NAME] (used to treat dementia)
Ezetimibe (used to treat high cholesterol), fish oil, mirabegron (used to treat over
active bladder), [MEDICATION NAME] (used to treat heartburn), [MEDICATION NAME] (an anti
depressant) Calcium with D, [MEDICATION NAME] (used to treat high cholesterol),[MEDICATION NAME] (a muscle relaxer) [MEDICATION NAME] ( an antidepressant used to treat
depression and anxiety disorders), vitamin D, [MEDICATION NAME] (used to treat anxiety),[MEDICATION NAME] 5/325 (a narcotic pain medication) and [MEDICATION NAME] (used to treat
nerve pain);
-[DIAGNOSES REDACTED].
Review of the nurse’s notes, showed on 12/7 (time not known) the resident got got his/her
insulin as ordered but did not eat. His/her blood sugar dropped to the 40s (normal 60-99).
The staff contacted the physician.
Review of the care plan dated 12/18/17, showed:
– A diabetic diet, 1800 calories and 60 grams of carbohydrates;
-fell at home prior to admission;
-Lives at home with [AGE] year old spouse, who rooms with him/her at the facility.
Review of the Social Services note dated 12/5/17, showed he/she still did not know if the
nursing home stay would be permanent. No further notes.
Review of the nurse’s notes showed the last entry dated 12/18/17. No note about the
discharge on 12/21/17.
Review of the discharge paper dated 12/21/17, showed a list of the resident’s medications,
but it did not indicate if/or how many pills were sent home with the resident. The
discharge paper did not include any education or training for the resident, or information
he/she knew how to take his/her medications or what follow up and services were needed to
go back home.
During interview on 2/23/18 at 1:48 P.M. and 2:23 P.M., with the Director of Nurses (DON)
and the Assistant Director of Nurses (ADON), the DON said the medication list should list
the prescription number and the number of pills released. There should be a training and
education sheet filled out on discharge. She could not find a discharge summary in the
nurse’s notes. The last note was 12/18/17. She did not find a social service note or
recapitulation of stay. There is a book at the nurse’s station that goes step by step what
to do for a discharge and it does show to include number of pills and directions and a
progress note. Home health was set up for the resident prior to discharge.
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 6)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure proper
perineal care (peri-care, cleansing of the surface area between the thighs, extending from
the pubic bone to the tail bone) for three of three observations (Residents #55, #85 and
#74). The census was 97.
1. Review of Resident #55’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/19/18, showed the following:
-Brief interview for mental status (BIMS, a screening tool used to assess cognitive
impairment) score of 0 out of 15, which showed severe impairment;
-Maximum care required for bed mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 2/23/18 at 10:04 A.M., showed Certified Nurse Aide (CNA) B transferred the
resident to his/her bed and removed the urine saturated brief. CNA B wiped the left and
right groin once on each side from front to back without changing areas of the cloth. With
a new cloth, he/she wiped the inner genital area six times front to back without changing
areas of the cloth.
During an interview on 2/23/18 at 10:15 A.M., CNA B said to always wipe from front to back
and change areas of the cloth with each wipe or change to a new cloth.
2. Review of Resident # 85’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 9 out of 15, which showed moderate cognitive impairment;
-[DIAGNOSES REDACTED].
-Dependent on staff for personal care and mobility;
-Frequently incontinent of bowel and bladder.
Observation on 2/23/18 at 11:03 A.M., showed the resident lay in bed on his/her back.
Certified Nurse Aid (CNA) D turned the resident to his/her left side and removed the urine
and dried stool saturated chux (disposable bed pad) from under the resident. He/she
returned resident to his/her back and cleansed the front peri area, then turned him/her to
the left side and cleansed the right buttock two times, wiping back to front. He/she
turned the resident to the right side and cleansed the left buttock two times from back to
front, then the inner buttock two times back to front, wiping stool toward the genitals
with each wipe.
During an interview on 2/23/18 CNA D said when providing peri-care, always wipe front to
back and change areas of the cloth or obtain a new cloth for each wipe. CNA D then said oh
my gosh, I did it wrong.
3. Review of Resident #74’s significant change MDS, dated [DATE], showed the following:
-BIMS score of 3 out of 15, which showed severe impairment;
-Limited assistance required for personal hygiene;
-Occasionally incontinent of bowel and bladder.
Observation on 2/26/18 at 5:25 A.M., showed CNA C obtained a warm wet cloth, applied peri
cleanser to the cloth and cleansed the resident’s peri area from front to back six times
without changing areas of the cloth and then, with a dry cloth, repeated the procedure.
He/she turned the resident to his/her right side and cleansed the inner and outer buttocks
from front to back, approximately six times without changing areas of the cloth and then,
with a dry cloth, repeated the procedure. CNA C changed gloves and applied barrier cream
to front peri area in back and forth motion.
During an interview on 2/26/18 at 5:35 A.M., CNA C said when providing peri-care, to
always wipe from the front to the back and change areas of the cloth with each wipe or
obtain a new cloth.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 7)
4. During an interview on 2/28/18 at 9:30 A.M., the Director of Nursing said when using a
washcloth, the area of the cloth needs to be changed with each wipe and when disposable
cloths are used, each cloth must be used for only one pass.
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
restorative nursing therapy for five of 20 sampled residents (Residents #13, #36, #50, #45
and #248). The census was 97.
1. Review of Resident #13’s quarterly MDS, a federally mandated assessment instrument
completed by facility staff, dated 12/1/17, showed the following:
-Total dependence on staff for transfers, dressing, toilet use, personal hygiene and
bathing;
-Upper and lower extremity impairment on both sides;
-Indwelling urinary catheter;
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Review of the resident’s restorative/maintenance nursing program record, showed the
following:
-Duration of program: three months;
-Frequency of program: three times a week;
-Approach: Resident to participate in bilateral lower extremity (BLE) passive range of
motion (staff moves the joint through the range of motion with no effort from the
resident) in all planes and bilateral upper extremity (BUE) strength, using 3 pounds in
all planes;
-January (YEAR), no documentation of BLE or BUE therapy received (MONTH) 11 through 17;
-February (YEAR), no documentation of any therapy received in February.
2. Review of Resident #36’s annual MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Required extensive assistance to dress and toilet;
-Limited range of motion in bilateral lower extremities;
-Received RT zero of seven days assessed.
Review of the resident’s (MONTH) (YEAR) POS, showed an active order, dated 8/9/17, for RT
three times a week for three months to maintain walking skills to assist with daily
routine.
Review of the resident’s (MONTH) (YEAR) restorative/maintenance nursing program record,
showed the following:
-No date for RT initiated;
-Duration of program: three months;
-Frequency of program: five times a week;
-Approach:
-Ambulation with wheeled walker with stand by assist/gait belt using wheeled walker and
gait belt with wheelchair follow;
-Transfers with stand by assist but decreased safety;
-Staff documented the resident received RT seven times between 1/1/18 and 1/31/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
Review of the resident’s (MONTH) (YEAR) restorative/maintenance nursing program record,
showed the following:
-Date restorative initiated: 2/19/18;
-Duration of program: three months;
-Frequency of program: four times a week;
-Approach:
-Walk with wheeled walker with gait belt;
-Transfer with stand by assist but decreased safety;
-Staff documented the resident received RT one time between 2/19/18 and 2/27/18.
3. Review of Resident #50’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Total dependence on staff for all activities of daily living (ADLs);
-Received PROM RT for three out of seven days assessed.
Review of the resident’s (MONTH) (YEAR) POS, showed an order, dated 2/19/18, for RT three
times a week for three months to BUE and BLE for strengthening and PROM/active ROM (AROM,
resident/patient performs the exercise to move the joint without any assistance) in order
to avoid contractures and decreased strength.
Review of the resident’s (MONTH) (YEAR) restorative/maintenance nursing program record,
showed the following:
-Date restorative initiated: 11/7/17;
-Duration of program: three months;
-Frequency of program: three times a week;
-Approach: BUE and BLE strengthening exercises in all planes. Twenty repetitions with
active assist;
-No documentation staff provided RT for the month of February.
4. Review of Resident #45’s admission MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Required extensive assistance with transfers, walking, dressing and toileting.
Review of the resident’s (MONTH) (YEAR) POS, showed an order, dated 1/24/18, to ride bike
for 15 minutes to maintain BUE and BLE strengthening and BUE and BLE strengthening
exercises to improve and maintain strength three times a week.
Review of the resident’s (MONTH) and (MONTH) (YEAR) restorative/maintenance nursing
program record, showed the following:
-Duration of program: three months;
-Frequency of program: three times a week;
-Approach:
-Ride bike for 15 minutes;
-BUE and BLE exercises with three pound weights in order to improve and maintain
strength;
-Staff documented RT provided two times from 1/24/18 through 1/31/18;
-Staff documented RT provided one time from 2/1/18 through 2/27/18.
5. Review of Resident #248’s admission MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Independent with most activities of daily living.
Review of the resident’s (MONTH) (YEAR) POS, showed an order, dated 2/9/18, for RT three
times a week for three months for walking with caregiver and wheeled walker.
Review of the resident’s (MONTH) (YEAR) restorative/maintenance nursing program record,
showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-Date RT Initiated: 2/9/18;
-Frequency: three times a week;
-Approach: ambulate resident with gait belt and wheeled walker and follow with wheelchair;
-Staff documented RT provided one time from 2/9/18 through 2/27/18.
6. During an interview at 12:15 A.M. on 2/27/18, Restorative aide (RTA) H said the main
RTA left a week or so ago. He/she is the back-up RTA and worked on the floor 99% of the
time. He/she had been off for a few days and came back yesterday. When he/she tried to do
RT with someone, he/she would be called to the floor because another staff member called
in. He/she had not had a chance to talk to the administration about it.
7. During an interview on 2/28/18 at 9:25 A.M., the Director of Nursing said the RTA left
with very little notice a week or so ago. RTA A was doing what he/she could to get the
restorative therapy done. They are looking to hire someone.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
appropriate care for residents with indwelling urinary catheters (a tube placed in the
body to drain urine from the bladder). The facility identified eight residents with
indwelling urinary catheters. Of those eight, four were chosen for the sample of 20 and
two of those did not receive appropriate positioning of the catheter tubing or collection
bag to facilitate drainage and prevent infections and/or orders were not obtained and the
catheter was not included on the care plan for one of them. (Residents #198 and #13). The
census was 97.
1. Review of Resident #198’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/20/17, showed the following:
-Extensive assistance required for dressing, toilet use and personal hygiene;
-Oxygen therapy;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/20/17, showed no documentation or
interventions regarding an indwelling urinary catheter.
Review of the resident’s physician’s orders [REDACTED].
Observations of the resident, showed the following:
-On 2/26/18 at 5:16 A.M. and 6:25 A.M., the resident lay in bed on his/her back with a
urine collection bag full of amber colored urine extended from the side of the bed and not
contained in a privacy bag. The catheter tubing, looped in a figure eight, contained
approximately 8 inches of urine unable to drain into the collection bag;
-On 2/26/18 at 8:54 A.M., the resident lay in bed on his/her back with an empty urine
collection bag, not contained in a privacy bag and the catheter tubing, still looped in a
figure eight;
-On 2/27/18 at 10:05 A.M. and 12:55 P.M., the resident lay in bed on his/her back with the
urine collection bag on the floor and not contained in a privacy bag. The catheter tubing
extended downward and then back up into the collection bag, with approximately 10 inches
of urine unable to drain into the bag.
2. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-Total dependence on staff for transfers, dressing, toilet use, personal hygiene and
bathing;
-Upper and lower extremity impairment on both sides;
-Indwelling urinary catheter;
-One Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a
red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured
blister) pressure ulcer (injury to the skin and/or underlying tissue, as a result of
pressure or friction);
-[DIAGNOSES REDACTED].
Observations of the resident, showed the following:
-On 02/26/18 at 11:49 A.M., the resident sat in a wheelchair at a dining room table with
the urine collection bag contained in a privacy bag and the entire bottom of the bag
rested on the floor under the wheelchair;
-On 02/28/18 at 8:49 A.M., the resident lay in bed with the urine collection bag contained
in a privacy bag, the catheter tubing looped in a figure eight and approximately 4 inches
of urine unable to drain into the collection bag.
3. During an interview on 2/28/17 at 9:25 A.M., the Director of Nursing said the urine
collection bag should be positioned below the bladder in a privacy bag. The bag should not
be on the floor and the urine should be able to flow freely into the collection bag, for
infection control purposes. The resident’s care plan should include the indwelling urinary
catheter and there should be an order for [REDACTED].
F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed the facility’s policy regarding [DEVICE] ([DEVICE], a small rubber tube
surgically inserted through the abdomen in to the stomach to administer nutrition, fluids
and medications) feedings by not recording on the bag the name of the formula, the date
and time hung and the resident’s name, failed to accurately determine the amount of
feeding administered per shift and obtain orders for the administration of water. The
facility identified four residents who received [DEVICE] feedings. Of those four, three
were chosen for the sample of 20 and problems were found with all three (Residents #50,
#29 and #15). The census was 97.
Review of the facility’s Enteral (tube) Feeding Policy, revised 1/1/18, showed the
following:
-Open enteral formula delivery systems will be changed every 24 hours;
-Staff will verify physician’s orders [REDACTED].>-Staff will prepare enteral feeding
as ordered by physician;
-Staff will complete feeding container label to include:
-Formula name;
-Strength;
-Rate;
-Time;
-Resident name;
-Nurse’s initials;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-Document total intake, separate into formula and water flush, on Medication
Administration Record [REDACTED].
1. Review of Resident #50’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/9/18, showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Total dependence on staff for all activities of daily living (ADLs);
-Nutrition provided through tube feeding.
Review of the resident’s physician order [REDACTED].
-An order, dated 7/10/17 and discontinued on 2/8/18, for [MEDICATION NAME] 1.5 (type of
tube feeding formula) at 45 cubic centimeters (cc) an hour and 200 cc water flush every
six hours;
-An order, dated 2/3/18, for every day and night shift to record intake via [DEVICE] and
clear the machine at the end of each shift;
-An order, dated 2/19/18, to increase tube feeding to 50 cc an hour, every morning and at
bedtime due to weight loss;
-Staff did not clarify with the physician the formula name or strength.
Review of the resident’s dietary recommendation, dated 2/19/18, showed his/her weight with
minimal changes. He/she received [MEDICATION NAME] 1.5 at 45 cc an hour with water flush
at 200 cc every six hours.
Review of the MAR, dated 2/1/18 through 2/28/18, showed the following:
-On 2/3/18 through 2/7/18, staff failed to record intake for either shift;
-On 2/8/18, day shift recorded an intake of 1140 cc and night shift recorded an intake of
450 cc;
-On 2/9/18, day shift recorded an intake of 450 cc and night shift recorded an intake of
654 cc;
-On 2/10/18, day shift recorded an intake of 1150 cc and night shift recorded an intake of
1112 cc;
-On 2/11/18, day shift recorded an intake of 1112 cc and night shift recorded an intake of
1 cc;
-On 2/12/18, day shift recorded an intake of 1175 cc and night shift recorded an intake of
1800 cc;
-On 2/13/18, day shift recorded an intake of 1700 cc and night shift recorded an intake of
225 cc;
-On 2/14/18, staff failed to record intake for either shift;
-On 2/15/18, day shift recorded an intake of 1140 cc and night shift recorded an intake of
1522 cc;
-On 2/16/18, day shift recorded an intake of 1200 cc and night shift recorded an intake of
560 cc;
-On 2/17/18, day shift recorded an intake of 450 cc and night shift recorded an intake of
1749 cc;
-On 2/18/18, day shift recorded an intake of 450 cc and night shift recorded an intake of
1200 cc;
-On 2/19/18, day shift recorded an intake of 1400 cc and night shift did not record an
intake;
-On 2/20/18, day shift recorded an intake of 1400 cc and night shift recorded an intake of
720 cc;
-On 2/21/18, day shift did not record an intake and night shift recorded an intake of 650
cc;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-On 2/22/18, day shift did not record an intake and night shift recorded an intake of 972
cc;
-On 2/23/18, day shift recorded an intake of 460 cc and night shift recorded an intake of
650 cc;
-On 2/24/18, day shift recorded an intake of 1340 cc and night shift recorded an intake of
600 cc;
-On 2/25/18, day shift did not record an intake and night shift recorded an intake of 758
cc;
-On 2/26/18, day shift recorded an intake of 1460 cc and night shift recorded an intake of
1035 cc;
-On 2/27/18, day shift recorded an intake of 1450 cc and night shift recorded an intake of
355 cc;
-The MAR indicated [REDACTED].
Observations of the resident, showed the following:
-On 2/22/18 at 11:39 A.M. and 3:16 P.M., the resident’s tube feeding infused via [DEVICE].
The bag of formula and water both showed a handwritten date of 2/20/18, and no other
information included on the bag;
-On 2/23/18 at 11:20 A.M., the same formula bag and water bag with a date of 2/20/18 in
use;
-On 2/26/18 at 5:34 A.M. and 8:30 A.M., the resident’s tube feeding infused via [DEVICE].
The formula bag had a label, which showed a date of 2/26/18 at 1:30 A.M., [MEDICATION
NAME] 1.5 and a staff initial;
-On 2/27/18 at 8:16 A.M. and 2:12 P.M. and 2/28/18 at 7:02 A.M., the formula bag with a
date of 2/26/18 remained in use;
-Staff failed to change the formula and water bag every 24 hours and include the name of
the resident, date, time, type, strength of formula used and rate infused.
2. Review of Resident #29’s MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Dependent on staff for personal hygiene and bed mobility.
Review of the POS [REDACTED] -An order, dated 2/1/18, to administer [MEDICATION NAME] 1.5 via [DEVICE] at 65 cc an hour
every day and night shift. Stop the feeding at 12:00 A.M. and resume at 6:00 A.M.;
-No order for the administration of water flushes.
Review of the MAR, dated 2/1/18 through 2/28/18, showed the following:
-On 2/8/18, night shift intake recorded as 587 cc;
-On 2/9/18, day shift intake recorded as 550 cc and night shift intake as 1170 cc;
-On 2/10/18, day shift intake not recorded and night shift intake recorded as 2215 cc;
-On 2/11/18, day shift intake not recorded and night shift intake recorded as 2225 cc;
-On 2/12/18, day shift intake not recorded and night shift intake recorded as 1288 cc;
-On 2/13/18, day shift intake recorded as 1450 cc and night shift intake recorded as 332
cc;
-On 2/14/18, day shift intake recorded as 1200 cc and night shift intake recorded as 390
cc;
-On 2/15/18, day shift intake recorded as 1780 cc and night shift intake recorded as 4530
cc;
-On 2/16/18, day shift intake not recorded and night shift intake recorded as 1 cc;
-On 2/17/18, day shift intake recorded as 1780 cc and night shift intake not recorded;
-On 2/18/18, day shift intake recorded as 990 cc and night shift intake not recorded;
-On 2/19/18, day shift intake recorded as 200 cc and night shift intake not recorded;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-On 2/20/18, day shift intake not recorded and night shift intake recorded as 770 cc;
-On 2/21/18, day shift intake recorded as 1300 cc and night shift intake recorded as 450
cc;
-On 2/22/18, day shift intake recorded as 1300 cc and night shift intake recorded as 100
cc;
-On 2/23/18, day shift intake recorded as 1300 cc and night shift intake recorded as 520
cc;
-On 2/24/18, day shift intake not recorded and night shift intake recorded as 1475 cc;
-On 2/25/18, day shift intake recorded as 365 cc and night shift intake recorded as 753
cc;
-On 2/26/18, day shift intake recorded as 200 cc and night shift intake recorded as 390
cc;
-On 2/27/18, day shift intake not recorded and night shift intake recorded as 390 cc;
-On 2/28/18, day shift intake recorded as 1200 cc and night shift intake not recorded;
-The MAR indicated [REDACTED].
Observations on 2/22/18 at 11:16 AM. and 3:50 P.M. and 2/23/18 at 10:40 A.M., showed two
bags hanging on the feeding pump, one contained water and one contained formula. The
formula infused via the pump at 65 cc an hour. Neither the bag that contained the formula
or the bag that contained the water contained a label with the resident’s name, the name
of the formula, the date or the time hung.
Observations on 2/26/18 at 7:00 A.M. and 10:10 A.M., 2/27/18 at 6:58 A.M. and 2:05 P.M.
and 2/28/18 at 7:37 A.M., showed the formula infused via the pump at 65 cc an hour, the
label attached to the formula bag read [MEDICATION NAME] 1.5 at 65 cc/hour, hung at 6:00
A.M. on 2/26/18. Staff noted no information on the water bag.
3. Review of Resident #15’s significant change MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Dependent on staff for all personal care and bed mobility;
-Nutrition provided by feeding tube.
Review of the (MONTH) (YEAR) POS, showed the following:
-An order, dated 2/10/18, to administer Glucerna 1.2 (type of tube feeding) via [DEVICE] at 60 cc every day and night shift;
-Flush [DEVICE] every four hours;
-No order regarding what to flush the [DEVICE] with or the amount.
Review of the MAR, dated 2/1/18 through 2/28/18, showed the following:
-Intake not recorded on the day shift from 2/1/18 through 2/28/18;
-Intake not recorded on the night shift from 2/1/18 through 2/27/18;
-Intake of 5320 cc recorded on the night shift of 2/28/18.
Observations on 2/22/18 at 12:48 P.M. and 4:12 P.M., 2/23/18 at 6:28 A.M. and 2:02 P.M.,
2/26/18 at 4:57 A.M., 2/27/18 at 11:12 A.M. and 1:51 P.M. and 2/28/18 at 7:07 A.M., showed
two bags hanging on the pump, one bag with water and the other with formula. The formula
infused via the pump at 60 cc an hour. Neither the formula bag or the water bag contained
a label with the resident’s name, the name of the formula, the date or the time hung.
4. During an interview on 2/28/18 at 9:30 A.M., the Director of Nursing said she expected
staff to follow orders. If an order is unclear, she expected the nurse taking the order to
clarify with the physician. Open enteral feeding bags should be replaced every 24 hours.
The Assistant Director of Nursing said staff should include the resident’s name, date and
time on the formula bag when it is hung. It is not necessary to include the formula name
and strength because the formula is kept in the resident’s room so staff are aware of the
formula infusing. An order should include the type and strength of formula because staff
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
would not know what to put in the bag. Intake should be documented as ordered and even if
there is no order to record intake they would expect it to be done. The intake of formula
and the intake of water should be recorded separately. The feeding pumps have two separate
gauges to record formula amount and water amount. It is the nurse’s responsibility to
clear the pumps at the end of their shift and record that amount.
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a coordinated plan of
care for resident [MEDICAL TREATMENT] (a process by which dissolved substances are removed
from a patient’s body by diffusion from one fluid compartment to another across a
semi-permeable membrane) treatment was developed with input from the facility and the[MEDICAL TREATMENT] treatment provider as evidenced by not having signed [MEDICAL
TREATMENT] contracts for two of three [MEDICAL TREATMENT] providers and failed to develop
contracts with two of two transportation providers who transport residents for [MEDICAL
TREATMENT] treatments. The facility identified five residents who received [MEDICAL
TREATMENT]. The census was 97.
During the entrance conference interview on 2/22/18 at 10:10 A.M., the Director of Nursing
(DON) said the [MEDICAL TREATMENT] and transportation contracts may not be in place
because they have had difficulty tying to get contracts from the providers. The facility
uses three [MEDICAL TREATMENT] centers for treatment and two transportation providers.
Review of the [MEDICAL TREATMENT] and transportation contract information provided by the
facility, showed the following:
-One facility [MEDICAL TREATMENT] provider contract;
-A sheet of paper with miscellaneous handwritten notes;
-No other contracts.
During an interview on 2/28/18 at 9:30 A.M., the DON said they had been working on getting
the contracts in place for approximately eight weeks. The sheet of paper with handwritten
notes, showed attempts to contact the [MEDICAL TREATMENT] providers. The administrator
agreed the facility needed to have contracts to coordinate the care for their residents.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.

Based on interview and record review, the facility failed to ensure certified nurse aides
received the required 12 hours of training and have a system to track the hours for four
of the six employees reviewed who worked at the facility for over a year. The census was
97.
Review of the training records provided by the facility, showed:
-Only six certified nurse aides (CNAs) worked at the facility for over a year;
-CNA N – received 4 hours and 45 minutes of training;
-CNA O – received 9 hours of training;
-CNA P – received 5 hours and 15 minutes of training;
-Certified medication technician/CNA F received 8 and 15 minutes of training.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
During an interview on 2/23/18 at 12:39 P.M., Licensed Practical Nurse Q, who is in charge
of CNA training, said she just took over in (MONTH) (YEAR). She was not aware of what the
12 hours should include. She does not know where the records prior to her starting might
be. She does not have them.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 26 opportunities observed, two errors
occurred, resulting in a 7.69% error rate (Resident’s #8 and #5). The census was 97.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/22/17, showed [DIAGNOSES
REDACTED].
Review of the undated physician order [REDACTED].
Observation on 2/21/18 at 4:08 P.M., showed Certified Medication Technician (CMT) E
administered tylenol 500 mg two tablets.
2. Review of Resident #5’s quarterly MDS, dated [DATE], showed a [DIAGNOSES REDACTED].
Review of the undated POS, in use during the survey, showed an order to administer two 200
mg cranberry capsules (used to prevent bacteria in the urinary tract and works as a water
pill) twice a day.
Observation on 2/22/18 at 7:25 A.M., showed CMT F administered one 250 mg capsule of
cranberry.
During an interview on 2/28/18 at 9:30 A.M., the Director of Nursing said medications are
to be administered according to the physician’s orders [REDACTED].

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to serve food under sanitary
conditions by not using utensils during food service. This had the potential to affect all
residents who eat at the facility. The census was 97.
1. Observations on 2/22/18 from 12:15 P.M. to 12:30 P.M., during the lunch meal service,
showed dietary aide (DA)J standing behind the steam cart. DA J donned gloves without first
washing his/her hands and used his/her gloved hands to assemble sandwiches behind the
steam cart. He/she also used gloved hands to scoop tomato wedges from the serving pan and
place on plates to be served to residents. He/she used his/her gloved hands to pull chips
from the bag and place on plates to be served to residents.
2. Observation on 2/26/18 from 12:23 P.M. to 12:33 P.M. during the lunch meal service,
showed Cook K and DA M walked behind the steam cart, donned gloves and began plating food
for service. Neither staff member washed or sanitized their hands prior to donning gloves.
DA M used his/her gloved hands to place bread on plates for egg sandwiches and to place
cheese puffs on plates to be served to residents.
3. Observation on 2/27/18 from 7:35 A.M. to 7:49 AM during the breakfast meal service,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265130

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

02/28/2018

NAME OF PROVIDER OF SUPPLIER

BIG BEND WOODS HEALTHCARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
showed Cook L behind the steam cart serving breakfast. He/she donned gloves without first
washing his/her hands. He/she then used gloved hands to pull biscuits from the serving pan
and then pull it apart and place it on a plate. He/she would then cover the biscuit with
gravy. The plates were then served to residents.
4. During an interview on 2/28/18 at 1:33 P.M., the dietary manager said she thought as
long as staff had on gloves and did not go from food to food, it was permissible to use
hands instead of utensils to serve food.
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