Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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.
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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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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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 | — | 3 | 0 |
| Aberdeen Heights | 3.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.