Big Spring Care Center for Rehab and Healthcare

Inspectors wroteBased on interview and record review, the facility failed to document notification of the responsible party or emergency contact of the resident's change in health condition, transfer to the hospital, and/or death of three residents (Resident #1, #2, and #3). The facility had a census of 42. Review of the facility provided policy, Notification of Changes, dated [DATE], showed the following:-The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Circumstances requiring notification include accidents resulting in injury or potential to require physician intervention; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to have process in place to ensure resident's received cardiopulmonary resuscitation (CPR - life-saving emergency procedure used when someone's breathing or heartbeat has stopped, combining chest compressions and rescue breaths to keep blood flowing to vital organs) per standard of practice when two of the four staff who performed CPR were not certified in CPR (official credential proving that you have completed a formal training course and know how to perform CPR, use an AED (automated external defibrillator), and manage choking or breathing emergencies), for one resident (Resident #1) prior to Emergency Medical Services arrival. The facility had a census of 42. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and in manner that protects if from possible contamination when multiple staff failed to wear hair nets and facial hair nets while in the kitchen during meal preparation and meal service. The facility census was 37. Review of the facility policy, dated 06/30/25, titled Dietary Employee Personal Hygiene, showed the following:-All dietary staff must wear hair restraints to prevent hair from contacting food;-Hair restraints include hair net, hat, and/or beard restraint. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's family/responsible party was notified of changes in condition when staff did not document that the responsible party or emergency contact notifications for residents' change in health condition and/or new physician orders for three residents (Resident #1, #2, and #3). The facility had a census of 35. Review of the facility titled Medication Orders, dated May 2025, showed staff to notify the resident's sponsor or family of new medication order. Review showed staff did not provide a policy related notifications of resident change in condition to responsible party or family members. 1. Review of Resident #1's face sheet showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain all resident medical records according to professional standards of practice when the facility failed to document hospice evaluation and admission and ensure the record was complete and accurately documented for one resident (Resident #1). The facility had a census of 35. Review showed the facility did not provide a policy related to nursing documentation and medical records accuracy. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when facility staff failed to obtain ordered medications in a timely fashion and failed to notify the physician of the missed doses one resident (Resident #1). The facility census was 34. Review of the facility's policy Unavailable Medications, revised 05/09/25, showed the following:-This facility shall use uniform guidelines for unavailable medications;-The facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications;-A STAT (immediately) supply of commonly used medications is maintained in-house for timely initiation of medications;-Medications may be unavailable for a number of reasons. [...]

Inspectors wrote1. Please refer to Event ID NXM312, exit 03/27/25. Based on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 44. Review of the facility's policy titled, Director of Food and Nutrition Services, undated, showed the following: -The Director of Food and Nutrition Services (DFNS) will be responsible for all aspects of the food and nutrition services department including, but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served; -The DFNS will be hired by corporate staff, the Administrator, or by the immediate supervisor of the position as deemed appropriate by the facility; -The DFNS will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. The facility census was 44. Review showed the facility did not provide a policy regarding new employee training. 1. Review showed the facility did not provide completed training documents or skills test for the current kitchen staff. During an interview on 01/29/25, at 2:25 P.M., Dietary Aide (DA) P said the following: -DA P started in the kitchen on 01/24/25; -DA P was still in training and the Dietary Manager (DM) had not gone over any kitchen policies with him/her; -DA P did not feel that he/she had enough training to be serving lunch to residents ,but was told to do so. During an interview on 01/29/25, at 3:00 P.M., [NAME] O said the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed store, prepare, distribute, and serve food in accordance with professional standards when staff failed to use effective hair restraints; failed to remove dented cans from use; failed to consistently label and date food; failed to ensure the dishwasher machine sanitation was at the appropriate level; failed to keep trash covered when not in use; failed to wash hands and equipment appropriately during food prep and service; and when staff failed to ensure non-food contact surfaces were clean and maintained in good repair. The facility census was 44. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the home was administered in an effective and efficient manner to ensure the highest practical well-being of all residents when the facility failed pay their bills in a timely manner. The facility census was 44. 1. Review of the facility's laboratory service invoices showed the following: -An invoice, dated 07/08/24, showed an amount owed of $2664.31. The invoice showed a note of terms of net 30 days; -An invoice, dated 08/08/24, showed an amount owed of $241.41. The invoice showed a note of terms of net 30 days; -An invoice, dated 09/05/24, showed an amount owed of $3466.70. The invoice showed a note of terms of net 30 days; -An invoice, dated 10/28/24, showed an amount owed of $2880.47. The invoice showed a note of terms of net 30 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene after personal cares for two residents (Residents #11 and #8), during and after wound care for one resident (Resident #34), and during and after feeding tube care for one resident (Resident #149). Staff also failed to follow Enhanced Barrier Precautions (EBP) for one resident (Resident #44) who had an indwelling catheter and failed to follow their Legionella (severe form of pneumonia) Water Management Program. The facility census was 44. Review of the facility policy titled Hand Hygiene Policy and Procedure, dated 2025, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #34) Foley catheter (sterile tube inserted into the bladder to drain urine) bag (bag that collects urine drained from a catheter inserted into the bladder) and when staff yelled in the dining room, and when the facility smoking scheduled was at the same time as lunch causing smoking residents to choose between smoke break and a hot meal. The facility census was 44. Review of facility policy titled Procedure for Ensuring Resident Rights, dated 2025, showed the following: -Residents are encouraged to participate in the Resident Council; -The facility will support and facilitate resident-led discussions on improving care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to act as a fiduciary and properly manage residents' funds when the facility failed to maintain access to a petty cash fund that ensured all resident could receive cash requests of less than $100.00 (or less then $50.00 if the resident received Medicaid) the same day for three residents (Resident #1, #26, and #44) out of a total sample of 17 residents. The facility census was 44. Review of the facility policy titled, Personal Needs Allowance (PNA), revised February 2019, showed the following: -All patients that the facility receives the original income checks in full are to be credited with $50.00 to their PNA account; -Petty cash in the amount of $750.00 is to be kept for small requests and should be replenished on a as needed basis; -All patients must sign their request and receipts acknowledging receipt of funds. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment when a handrail in a common area remained in an unsafe condition, chair cushions in a common area were in disrepair, and two walls of one resident's (Resident #16) room were damaged. A sample of 17 residents was reviewed; the facility census was 44. Review of a facility policy entitled Maintenance Service, revised December 2009, showed the following: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; -Functions of maintenance personnel include maintaining the building in good repair and free from hazards; -The Maintenance Director is responsible for maintaining work order requests. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system or records that showed provided an accurate reconciliation of controlled medications when facility's licensed staff failed to ensure the Emergency Kit (E-Kit) and the form titled BNDD (Bureau of Narcotics and Dangerous Drugs) Kit Administration Record matched the current narcotic count, when a random count of the narcotics in the E-Kit with the nurse did not match. The facility census was 44. Review of the facility provided policy titled BNDD Kit Policy, dated March 2019, showed the following: -The BNDD kit is owned, managed, and controlled by the long-term care facility; -The BNDD kit will be used when extenuating circumstances exist; -When accessing/opening the BNDD kit the nurse will contact the physician to obtain an order to access the BNDD kit and an order to administer the medication; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the use of a seat belt, failed to obtain written consent for use of the seat belt, failed to document what less restrictive options were attempted, failed to document risk versus benefit review related to the seat belt use, failed to obtain a physician's order for use of the seat belt, and failed to care plan the use of the seat belt for one resident (Resident #11) who was unable to effectively and consistently remove the seat belt without staff assistance. The facility census was 44. Review of the facility provided policy titled Use of Restraints, dated December 2007, showed the following: -Restraints should only be used for the safety and well-being of the resident and only after alternatives have been tried unsuccessfully; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to fully implement their abuse and neglect policies and procedures when staff failed to report an allegation of abuse made by one resident (Resident #1), who reported to the charge nurse that another resident (Resident #2) kissed him/her on the mouth, immediately to facility Administrator and within two hours to the state survey agency (Department of Health and Senior Services - DHSS). A sample of four residents was selected for review. The facility census was 46. Review of the facility's policy titled Abuse and Neglect Policy, revised September 2024, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received care per professional standards of practice when staff failed to obtain ordered blood tests in a timely fashion for one resident (Resident #8) out of a total sample of 17 residents. The facility census was 44. Review of the facility's policy titled, Laboratory Services For Nursing Staff, dated 2025, showed the following: -The facility shall provide or arrange for laboratory services to meet residents' medical needs; -The nursing staff is responsible for coordinating, collecting, and documenting laboratory specimens in accordance with state and federal regulations; -All laboratory results must be reviewed, documented, and communicated to the provider in a timely manner. 1. Review of Resident #8's face sheet (gives basic profile information) showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for residents on oxygen per professional standards of practice when staff failed to administer oxygen per physician orders for two residents (Resident #5 and Resident #7). The facility census was 44. Review of the facility's policy titled Monitoring Oxygen Use and Oxygen Saturation, undated, showed the following: -Purpose to ensure the safe and effective use of oxygen therapy and comply with regulatory requirements; -Applies to all residents receiving oxygen therapy and the nursing staff responsible for their care; -Oxygen therapy must be prescribed by a physician, including flow rate (liters per minute - lpm) and oxygen saturation range; -Only licensed nurses may adjust oxygen flow rates based on the physician's order; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis (the cleaning of the blood with a machine due to the kidneys not working) services per professional standards of practice when the facility failed to document routine assessment and monitoring of the dialysis site and failed to document ongoing communication with the dialysis center for one resident (Resident #2) who received dialysis. The facility census was 44. Review of the facility's policy titled Dialysis Policy, dated 2025, showed the following: -Purpose to establish guidelines for nursing staff to manage and support residents undergoing dialysis, ensuring safety, infection control, and continuity of care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring for one resident (Resident #1), out of 17 sampled residents, who informed staff of past trauma. The facility census was 44 residents. Review of the facility's policy entitled Trauma-Informed Care, dated 2025, showed the following: -The facility will provide trauma-informed care (TIC) that recognizes, assesses, and responds to the effects of trauma on residents; -Staff will be trained in trauma-informed care principles, focusing on psychological safety, trust, and individualized care; -The facility will integrate evidence-based interventions and coordinate with behavioral health providers when necessary; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a functional environment for all residents, when staff failed to maintain a bariatric Hoyer weight scale when staff were unable to take a weight on one resident (Resident #8), out of a total sample of 17 residents, for six months for one resident. The facility census was 44. Review of the facility's policy titled Weight Assessment and Intervention, revised September 2008, showed the following: -The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents; -The dietician will review the unit weight record monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight changes has been met. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer their resources in a an effective manner to assure the highest practical well-being of all residents when the facility failed pay their DME (durable medical equipment) company per their rental agreement by the due date to ensure residents' medical equipment could remain in the building. This resulted in the company arriving on site to take back equipment actively being used by residents. This had the potential to affect all residents in the facility. The facility census was 45. 1. Review of the facility's DME invoices showed the following: -An invoice, dated 12/31/21, stamped past due, with a due date of 01/30/22. The invoice total was $2123.00 with a balance due after last payment of $325.50; -An invoice, dated 01/31/22, stamped past due, with a due date of 03/02/22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared, and distributed in a manner to prevent possibly contamination when staff failed to maintain food contact services as clean, failed to keep ice machine free of black substances, failed to store bulk food scoops outside of the the containers, and failed to date and store refrigerated foods appropriately. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 51 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety, General Food Preparation and Handling showed the following: -The kitchen will be kept neat and orderly; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a sanitary environment when staff failed to keep non-food contact surfaces, including the floor, vents, ceiling lights, and the outside of the dishwasher, clean and well maintained in the kitchen, dry storage area, and dining rooms. This has the potential to affect all residents who consumed food from the facility. The facility census was 51. Review of the Food and Drug Administration (FDA) 2013 Food Code showed non-food contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris Review of the facility's Policy & Procedure Manual, Chapter 3: Food Production and Food Safety 3-26, General Food Preparation and Handling showed the the kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow their emergency water supply procedures when staff did not have a three day supple of water on hand for use in the case of loss of normal water supply. The facility census was 51. Review of an agreement letter with a water provider, undated, showed the following information: -The provider will assist in supplying bottled water to the facility in the event of a fire, hurricane, tornado, flood or loss of power in or around the facility; -Adequate water will be provided to service the facility's residents: 1.5 gallons of water per day per resident, family members and staff; -Response should be available within 48 hours of notification; however, is subject to facility accessibility and availability of delivery equipment and products consistent with the nature of the emergency event; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Criminal Background Check (CBC) on two of ten sampled staff (Dietary Aide (DA) O and Maintenance Supervisor) and failed to ensure that three staff (Certified Nurse Aide (CNA) H, DA O, and Maintenance Supervisor) were not on the Missouri Employee Disqualification List (EDL - a list of individuals who are determined to be not able to work in long term care). A sample of 10 staff were reviewed in a home with a census of 51. Review of the facility provided policy, titled Background Checks Policy and Procedure, undated, showed the following information: [...]

Inspectors wroteBased on interview and record review, the facility failed to give written transfer notice to the resident and/or resident's representative for six residents (Residents #3, #14, #13, #26, #32, and #35) who were transferred out to the hospital. A sample of of 18 residents were reviewed in a facility with a census of 51. Review showed the facility did not provide a policy pertaining to written transfer notices of a resident's transfer to the hospital. Review of the facility provided policy, titled Transfer or Discharge Documentation, dated December 2016, showed the following information: -When a resident is transferred or discharged , detail of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received a written notice of the bed-hold policy upon transfer when staff failed to provide six residents (Residents #3, #14, #13, #26, #32, and #35) of 18 sampled residents, written notices of the facility's bed-hold policy when transferred to the hospital. The facility census was 51. Review of the facility provided policy, titled Bed Holds and Returns, undated, showed prior to transfers and therapeutic leaves, residents' representatives will be informed in writing of the bed-hold and return policy; 1. Review of Resident 3's face sheet (gives basic profile information) showed an admission date of 12/16/22. Review of the resident's nurses' notes showed the following: -On 03/09/23, at 3:30 P.M., resident complained of shortness of breath and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's order for and care plan the use of side rails for one resident (Resident #10) and failed to obtain written consent for side rail use, failed to complete a documented side rail assessment including risks versus benefits,and failed to complete gap assessments prior to installing side rails for three residents (Residents #10, #33, and #9) in a sample of 24 residents. The facility census was 51. Review of the facilities policy, titled Bed Safety, revised December 2007, showed the following: -Resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants, when staff failed to use appropriate hand hygiene while completing incontinent care for one resident (Resident #150) for one of 18 sampled residents Staff failed to complete and fully document tuberculosis (TB - infectious bacterial disease characterized by the growth of nodules (tubercles) in the tissues, especially the lungs) testing for three staff members (Certified Nurse Aide (CNA) H, Maintenance Supervisor, and Certified Medication Tech (CMT) B), in a sample of 10 staff members. The facility failed to accurately place, read, and record admission tuberculosis (testing for one resident (Resident #150) in a timely manner, out of a sample of 18 residents. The facility census was 51. [...]

Inspectors wroteBased on record review and interviews, the facility failed to assure five residents (Residents #9, #32, #44 #102, and #150) were offered any pneumococcal vaccinations (protects against serious and potentially fatal pneumococcal infections - also known as the pneumonia vaccines. Pneumococcal infections can lead to pneumonia, blood poisoning (sepsis) and meningitis) out of a sample of 18 residents. The facility census was 51. Record review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 03/15/23, showed the following information: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan (the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) within 48 hours for one resident (Resident #150) out of a sample of 18 residents. The facility had a census of 51. Review of the facility provided policy, titled Care Plans - Baseline. undated, showed the following information: -A baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission; -To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (amount of medical assistance the resident wishes to receive if found though pulse or respirations) matched throughout the medical record for one resident (Resident #26) out of 18 sampled residents. The facility census was 51. Review of the facility policy, titled Do Not Resuscitate Order, dated [DATE], showed the following information: -The facility will not use cardiopulmonary resuscitation (CPR - giving strong, rapid pushes to the chest to keep blood moving through the body) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order (DNR - instructs health care providers not to do CPR if a person's breathing stops or the heart stops beating) in effect; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication regimen was free from unnecessary medications when the facility failed to implement gradual dose reductions (GDR) for one resident (Resident #39) in a selected sample of 16 residents. The facility's census was 51. Review showed the home did not provide a policy addressing GDRs. 1. Review of Resident #39's face sheet (gives basic profile information) showed the following: -admission date of 01/11/22; -Diagnoses included Alzheimer's disease, unspecified intellectual disabilities, unspecified psychosis not due to a substance or now physiological condition, recurrent major depressive disorder with psychotic symptoms, vascular dementia with behavioral disturbance, anxiety disorder, and impulse disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean surfaces in a clean sanitary manner and failed to store and air dry drinking glasses in a sanitary manner. The facility census was 42. Record review of the facility's policy, titled Sanitization, dated 2001 and revised October 2008, showed the following: -All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter ad rubbish and protected from rodents, roaches, flies and other insects; -All utensils, counters, shelves and equipment shall be kept clean. 1. Observation of the kitchen on 12/09/19, at 9:20 A. M., showed the following: -The window ledge just above the sink had approximately 75-100 small flies, lying dead across the surface of the ledge; -One fly was squished on the window, about half way up; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain a physician's order for the placement and maintenance of a percutaneous endoscopic gastrostomy (PEG tube - feeding tube directly into the stomach), to include a valid, clinical rationale for the PEG tube, for one resident (Resident #35). A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policies showed the facility did not provide a policy for what PEG tube orders should include or labeling requirements of the bag. 1. Record review of Resident #35's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/7/19, showed the following information: -Most recent readmission to the facility 10/23/19; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for the use of side rails and failed to complete side rail safety checks and regular inspections of the bed frame and side rails for the risk of entrapment for two residents (Resident #16 and #24) . A sample of 12 residents was selected for review; the facility census was 42. Record review of the facility's policy entitled, Proper Use of Side Rails, dated 2001 and revised December 2016, showed the following information: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; [...]