Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Big Spring Center For Skilled Care during CMS and state inspections, most recent first.
Personal refrigerator food storage and temperature monitoring were not maintained for several resident rooms. Multiple refrigerators contained assorted food items, including dairy, condiments, sausages, and beverages, while no temp logs were found and internal temps were documented above the required range in some rooms. The ADM, DON, and DM stated residents or families were generally responsible for cleaning and maintaining the refrigerators, but there was no assigned daily staff task or log for monitoring temps or expired food.
A resident with Parkinson’s disease, moderate cognitive impairment, psychotic disorder, depression, and anxiety had an outdated PASARR PL1 that still indicated no mental illness. The MDS Coordinator stated she was responsible for keeping PL1s accurate and updated but was unaware of the psychotic disorder diagnosis, and no additional PL1 screening was available in the record.
Improper incontinent care was observed for a resident with Alzheimer's disease, muscle weakness, and frequent bladder incontinence who needed assistance with toileting hygiene. A CNA cleaned only part of the perineal area, did not clean the buttocks or front peri-area as observed, and then applied a new brief. The CNA acknowledged the omission, and the DON and ADM stated staff were expected to provide proper incontinent care per facility policy.
Failure to change gloves during incontinent care. A CNA provided perineal care to a resident with Alzheimer's disease and muscle weakness, cleaning from the vaginal area to the anus while bowel was present on the wipes, but did not change gloves when moving from dirty to clean tasks. The resident was frequently incontinent and required assistance with toileting hygiene. The CNA later acknowledged the error, and the DON and ADM stated gloves should be changed when contaminated and during incontinent care.
Two residents with dementia and wandering behaviors were involved in a physical altercation, during which staff failed to immediately report the incident and assess those involved, as required by facility policy. Multiple staff members, including a CNA, an LPN, and supervisory staff, did not follow abuse prevention and reporting procedures, resulting in delayed notification and assessment after the event.
The facility failed to inform residents about their rights to file grievances, resulting in 12 residents being unaware of how to access grievance forms or file grievances anonymously. The grievance procedure was not discussed in Resident Council meetings, and postings lacked necessary instructions. The Administrator acknowledged the oversight and the potential for unresolved resident issues.
The facility failed to properly store, label, and date food items in the kitchen's walk-in refrigerator, as observed during a survey. Several food items were found unsealed, unlabeled, or with expired dates. Staff interviews confirmed that all food should be sealed, dated, and used or discarded by the expiration date, as per facility policy. The Dietary Manager and dietary staff are responsible for monitoring compliance.
The facility failed to maintain an effective infection control program, as several CNAs did not adhere to proper hand hygiene protocols while providing care to residents. A CNA did not wash hands before assisting with incontinent care for a resident with multiple serious health conditions. Similarly, two CNAs did not follow proper handwashing procedures while providing peri care for another resident, who was cognitively intact and had a history of type 2 diabetes. Interviews revealed a lack of understanding and adherence to the facility's hand hygiene policy.
A facility failed to accurately complete the PASRR Level I assessment for a resident with PTSD, marking them as not having a mental illness. The MDS nurse was unaware of the PTSD diagnosis at admission, and no PASRR evaluation was conducted. Interviews revealed that the MDS nurse is responsible for ensuring PASRR accuracy, and the administrator stressed the importance of accurate assessments to prevent treatment delays.
A resident with cognitive impairment requested a room change due to feeling uncomfortable with a CNA who refused to change her adult brief. The Social Worker and DON did not file a grievance or investigate the issue, as the resident did not appear visibly upset. The facility's grievance policy was not followed, and the Administrator was unaware of the situation.
A resident in an LTC facility reported feeling uncomfortable and unsafe due to staff treatment, leading to a room change request. The facility failed to follow its abuse prevention policies, as staff did not report or investigate the resident's allegations. Interviews revealed that the resident felt neglected and dirty, and the facility's system for monitoring compliance with abuse policies was inadequate.
A resident received another resident's medications due to pre-cupping and labeling confusion, resulting in a significant drop in blood pressure and hospitalization. The error was identified and reported by the CMA, but the family was not immediately informed. The facility's medication administration policy was not followed.
A resident was administered another resident's medication, leading to a significant drop in blood pressure and hospitalization. The error was identified by a CMA and reported to an LVN, but the physician and family were not notified immediately, contrary to facility policy.
A resident with multiple medical conditions and a high risk for falls was injured during a transfer using a sliding board by an untrained nurse aide. The incident was not reported immediately, and the resident later reported the fall, leading to his discharge from the facility. Staff interviews revealed lapses in training and communication.
Personal Refrigerator Food Storage and Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ food items in personal refrigerators for 4 of 21 resident rooms reviewed. During observations, multiple resident room refrigerators contained a variety of food items, including condiments, dairy products, sausages, cheese, yogurt, and beverages, while no temperature logs were located on or around the refrigerators. In one room, the refrigerator thermometer showed 42 F on two separate observations; in another room, it showed 46 F on two separate observations. In one refrigerator, food items included five bottles of grape and strawberry jelly, peanut butter, swirled peanut butter and jelly, soda, mayonnaise, sour cream, pickles, and water, with the internal temperature recorded at 42 F. In another refrigerator, four cans of soda and two containers of unknown food contents were present, and the thermometer showed 46 F. In a third refrigerator, two packs of hot link sausages were present, including one opened package and one unopened package, along with a bottle of mustard that had an open date written as 04/03/22 and a bottle of water. In a fourth refrigerator, items included snack packs with unknown white contents, yogurt, cream cheese spread, butter, chocolate bars, American cheese singles, mayonnaise, grape jelly, shredded cheese, and eleven cans of soda, including two damaged and misshaped cans. The ADM stated residents were responsible for maintaining their own personal refrigerators, including cleaning them, storing food properly, and discarding spoiled items, and said staff were not assigned to check personal refrigerators or document temperatures on a log. The DON stated staff could assist residents if needed and that expired or spoiled food could be discarded after notifying the resident and getting permission, but also stated there was no daily checklist or task assigned for staff to check refrigerators. The DM stated she placed thermometers in personal refrigerators and checked temperatures during morning rounds, but she did not keep temperature logs. The facility policy stated residents and/or responsible parties were responsible for care and maintenance of personal refrigerators, that housekeeping could assist at least weekly, and that food that is expired, spoiled, or moldy could be discarded.
PASARR Level 1 Not Updated for Resident With Psychotic Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program for one resident reviewed for PASARR screening. Resident #13 had an undated face sheet showing a history of Parkinson’s disease, psychotic disorder with hallucinations due to a known physiological condition, and anxiety. The quarterly MDS dated [DATE] showed a BIM’s score of 12, indicating moderate cognitive impairment, and listed psychotic disorder, depression, and anxiety as active diagnoses. The care plan initiated on 1/07/2025 included a focus that the resident required an antipsychotic medication, with goals and interventions related to medication administration, pharmacy consultation, and education about risks and side effects. Resident #13’s PASARR Level 1 form dated 4/19/2022 indicated “No” for mental illness under Section C0100, and no additional PL1 screenings were provided by the facility. During interview, the MDS Coordinator stated she was responsible for ensuring PL1s were accurate and updated, but she was not aware of the resident’s psychotic disorder diagnosis and acknowledged that the resident did not have another PL1 available. The Administrator stated the MDS Coordinator was responsible for ensuring PL1s were accurate and updated and said new mental illness diagnoses were discussed in weekly IDT meetings, but Resident #13’s diagnosis may have been missed.
Improper Incontinent Care During Perineal Hygiene
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was frequently incontinent of bladder and required supervision or touching assistance for toileting hygiene. The resident had diagnoses of Alzheimer's disease and muscle weakness, and the care plan directed incontinence care at least every 2 hours. During an observation, a CNA provided incontinent care while the resident was lying on her left side, cleaned from the vaginal area to the anus, and then placed a new brief without any observation of cleaning the buttocks area or the peri-area on the front side. The resident was then turned onto her back and the brief was fastened. During interview, the CNA stated there was no reason she did not clean the resident's buttocks area or front side and acknowledged she had been trained in incontinent care. The CNA stated she should have cleaned the front side of the resident and identified urinary tract infection as a potential negative outcome. The DON and ADM stated CNAs were responsible for proper incontinent care and that staff had been trained and competency checked, and the facility policy required cleaning the pubis and perineal area from clean to dirty and then cleaning the buttocks and anal area after repositioning the resident.
Failure to Change Gloves During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for infection control. During observation of incontinent care for a resident admitted with Alzheimer's Disease and muscle weakness, the CNA cleaned the resident from the vaginal area to the anus while the resident was lying on her side, and bowel was observed on the disposable wipes during cleaning. No glove change was observed when the CNA moved from dirty to clean tasks, and the CNA later removed gloves and gown and washed hands after the care was completed. The resident's quarterly MDS indicated the resident required supervision or touching assistance for toileting hygiene and was frequently incontinent. The care plan identified occasional bladder incontinence with interventions to provide incontinence care at least every 2 hours. During interview, the CNA stated there was no reason she did not change her gloves, said she got nervous and did not have any extras, and acknowledged she should have changed her gloves when going from dirty to clean. The DON and ADM both stated gloves should be changed when contaminated and during incontinent care, and the CNA proficiency audit for perineal care documented satisfactory skills for proper handwashing and preventing cross contamination.
Failure to Implement and Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement and follow its written policies and procedures designed to prohibit and prevent abuse and neglect, specifically in relation to a resident-to-resident altercation involving two residents with dementia and wandering behaviors. On the day of the incident, a CNA witnessed one resident hitting another with a shoe and restraining him on a bed, while the second resident was yelling for help. The CNA separated the residents and attempted to report the incident to the nursing staff, but no one was available at the nurse's station. The CNA did not report the incident to the charge nurse or other appropriate personnel until the following day, resulting in a delay in both assessment and reporting. Other staff members, including another CNA and an LVN who were informed of the altercation during shift change, also failed to report the incident to facility management, assuming it had already been reported. The ADON was not made aware of the incident until the next morning, at which point both residents were assessed. One resident was found to have a new abrasion on his nose, while the other had no visible injuries. The delay in reporting and assessment was contrary to the facility's abuse policy, which requires immediate reporting and assessment of all residents involved in such incidents. Interviews with staff and record reviews confirmed that the facility's abuse prevention policies were not followed by multiple staff members, including the CNA, LVN, ADON, and the former administrator. The facility's policy mandates that all allegations of abuse be reported immediately to the administrator and appropriate authorities, and that residents involved in altercations be promptly assessed for injuries. The failure to adhere to these procedures resulted in a delayed response to the incident and a lack of timely assessment and reporting, as required by both facility policy and regulatory standards.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns. During a Resident Council meeting, 12 confidential residents reported that they did not have access to the Grievance form, were unaware of the option to file grievances anonymously, and had not been informed about the grievance procedure. Additionally, they had not seen any postings of the grievance procedure in prominent locations within the facility. These residents were also unaware of where to obtain a grievance form, whom to submit it to, and the process that follows once a grievance is filed. The facility's grievance policy, last updated in 2016, states that a copy of the grievance/complaint procedure should be posted on the resident bulletin board. However, observations revealed that while information about the administrator being the grievance officer was displayed, instructions regarding the grievance procedure were not included in any prominent postings. Grievance forms were not readily available, and there was no established procedure for submitting grievances anonymously. An interview with the Administrator (ADM) revealed that she was responsible for overseeing the grievance process and that grievance forms were kept in a folder outside her office. However, the ADM acknowledged that the forms' availability was not helpful if residents did not know where to find them. The ADM also stated that staff typically completed grievance forms for residents, and there was no procedure for anonymous submissions, despite the presence of a box outside her office that could be used for this purpose. The ADM was unaware that the grievance procedure was not being discussed in Resident Council meetings, and she recognized that the lack of adherence to the grievance policy could result in unresolved resident issues.
Failure to Properly Store and Date Food in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not properly store, label, and date food items in the walk-in refrigerator. Observations revealed several food items, including a plastic container with mixed fruit, a metal bowl covered with tin foil, and containers labeled with expired dates or no dates at all. These items were not sealed or dated as required by the facility's policy. Interviews with staff members, including the Dietary Manager (DM) and another staff member, confirmed that all food in the refrigerator should be sealed and dated, and used or discarded by the expiration date. The staff acknowledged that they had received training on these procedures. The Administrator (ADM) also stated that the DM and dietary staff are responsible for monitoring the refrigerator and ensuring compliance with food storage policies. The facility's policy, dated 2012, mandates that open packages of food be stored in closed containers with covers or sealed bags and dated when opened.
Inadequate Hand Hygiene Practices in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of several CNAs who did not adhere to proper hand hygiene protocols while providing care to residents. Specifically, CNA E did not wash hands before assisting with incontinent care for Resident #40, who had a history of multiple serious health conditions, including pneumonia, sepsis, and end-stage renal disease. During the care process, CNA E also failed to wash hands after removing gloves and only rinsed hands without using soap, which is against the facility's hand hygiene policy. Similarly, CNAs H and I did not follow proper handwashing procedures while providing peri care for Resident #51, who was cognitively intact and had a history of type 2 diabetes and other health issues. Both CNAs washed their hands for significantly less time than required by the facility's policy and the CDC guidelines. Additionally, CNA I began interacting with the resident before donning the necessary PPE, and both CNAs struggled to clean dried feces from the resident, indicating inadequate care. Interviews with the CNAs revealed a lack of understanding and adherence to the facility's hand hygiene policy, despite having received training. The facility's administrator confirmed the expectation for proper handwashing and the potential risks of not following these protocols, such as the spread of infections and skin breakdown. The facility's policies on hand hygiene, enhanced barrier precautions, and perineal care were not followed, leading to the observed deficiencies.
Inaccurate PASRR Screening for Resident with PTSD
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessment for a resident, which did not reflect the resident's diagnosis of Post-Traumatic Stress Disorder (PTSD). This oversight was identified during a review of the resident's records, which showed that the PASRR Level I screenings conducted on two separate occasions incorrectly marked the resident as not having a mental illness, despite the presence of a PTSD diagnosis upon admission. The MDS nurse, responsible for checking the PASRR for accuracy, was unaware of the PTSD diagnosis at the time of admission, and no PASRR evaluation was conducted. Interviews with the MDS nurse and the facility administrator revealed that the MDS nurse was not in her current role at the time of the resident's admission but is responsible for ensuring the accuracy of PASRR screenings and entering admitting diagnoses into the electronic medical record. The administrator confirmed that the MDS Coordinator is responsible for completing PASRR evaluations and emphasized the importance of accurate PASRR assessments to prevent delays in treatment and referrals. The facility's policy requires a review of the PASRR Level 1 screening form for completion and correctness prior to admission, but this was not adhered to in this case.
Failure to Address Resident Grievance Regarding Staff Treatment
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who requested a room change due to feeling uncomfortable with a staff member. The resident, who had a cognitive communication deficit and was moderately impaired, expressed that a CNA was mean to her and refused to change her adult brief, making her feel unsafe. Despite the resident's request to move rooms, no grievance was filed, and the reason for the move was not documented or investigated. The Social Worker acknowledged the resident's request to move but did not file a grievance or investigate further, as the resident did not appear visibly upset. The Social Worker was aware of the facility's grievance policy but did not follow it, which could potentially harm residents or compromise their rights. The Director of Nursing (DON) also did not follow up on the reason for the room change, assuming it was the resident's choice without further inquiry. The Administrator, who was new to the facility, was not informed of the resident's discomfort or the grievance process not being followed. The facility's grievance policy requires that grievances be reported and investigated, with the Administrator or their designee overseeing the process. However, the policy was not adhered to, and the resident's concerns were not addressed according to the established procedures.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for one of the residents reviewed for abuse. The Social Worker did not follow the facility's abuse policy by failing to report the resident's request for a room change and her discomfort with the staff to the abuse preventionist. Additionally, a confidential interview revealed that the facility's abuse policy was not followed when the resident reported feeling uncomfortable due to staff treatment from several CNAs and an LVN. The report highlights that LVN C did not report an allegation of abuse to the abuse preventionist when informed by an unidentified staff member that the resident felt uncomfortable and dirty due to the staff. The facility's policies, including those on resident rights and abuse/neglect, emphasize the importance of reporting and investigating any allegations of abuse or neglect. However, the facility's staff, including the Social Worker and LVN C, failed to adhere to these policies, which could place residents at risk for abuse and neglect. Interviews with the resident and staff revealed that the resident felt unsafe and uncomfortable due to the actions of certain staff members. Despite the resident's request for a room change and her expressed discomfort, the facility did not document or investigate the allegations. The DON and ADM were unaware of the resident's concerns, and the facility's system for monitoring and ensuring compliance with abuse policies was inadequate, as evidenced by the lack of reporting and investigation of the resident's allegations.
Significant Medication Error Due to Pre-Cupping and Labeling Confusion
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident #1. Certified Medication Aide (CMA) A administered medications intended for Resident #2 to Resident #1, resulting in a significant drop in Resident #1's blood pressure and necessitating her transfer to the hospital. The error was identified when CMA A realized the mistake shortly after administering the medications and reported it to Licensed Vocational Nurse (LVN) A. LVN A assessed Resident #1 and found her blood pressure to be critically low, leading to the initiation of intravenous fluids and eventual transfer to the emergency room as per the physician's orders. The family member of Resident #1 was not immediately informed about the medication error, which caused further distress when they learned about it from the hospital staff later on. The facility's Director of Nursing (DON) was also not promptly informed about the urgency of the situation by LVN A. The error was attributed to the practice of pre-cupping medications and labeling them with residents' names, which led to confusion due to the similarity in the names of Resident #1 and Resident #2. CMA A, who was filling in for another CMA, was not familiar with the medication carts and the process, which contributed to the error. The facility's policy on medication administration was not followed, as medications were removed from their unit dose packaging in advance, increasing the risk of drug administration errors.
Failure to Notify Physician and Family of Medication Error
Penalty
Summary
The facility failed to immediately notify the resident's physician and representative when there was a significant change in the resident's physical status. Specifically, Resident #1 was administered Resident #2's medication, which led to a significant drop in blood pressure, necessitating an IV administration and subsequent transfer to the hospital. The error was discovered by a Certified Medication Aide (CMA) who reported it to a Licensed Vocational Nurse (LVN), but the physician and responsible party were not notified immediately as required by the facility's policy. Resident #1, who had multiple diagnoses including Alzheimer's disease, epilepsy, and hypertension, was mistakenly given medications intended for Resident #2. This error occurred because the medications were pre-cupped and labeled incorrectly, leading to confusion. The CMA identified the error shortly after administration and reported it to the LVN, who then monitored the resident's blood pressure, which remained critically low. Despite the severity of the situation, the physician and the resident's family were not informed immediately. Interviews with staff revealed that the medication error was due to improper labeling and pre-cupping of medications. The DON was not aware of the pre-cupping practice and was informed of the error only after the resident's condition had worsened. The facility's policies clearly state that any medication errors should be reported immediately to the physician and the resident's family, which did not happen in this case. This failure to follow protocol placed the resident at significant risk and delayed appropriate medical intervention.
Failure to Provide Adequate Supervision and Training for Resident Transfers
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, specifically for one resident who was transferred using a sliding board by a nurse aide who had not been trained to use it. The resident, who had a pressure ulcer on his right heel and an acquired absence of his left leg below the knee, was cognitively intact and used a wheelchair. During a transfer to the toilet, the sliding board moved, causing the resident to fall and injure his hip area. The incident was not reported immediately, and the nurse aide admitted to not having received training on the use of the sliding board. The resident's medical records indicated he was at medium risk for falls due to various conditions, including hypotension, vertigo, Parkinson's disease, and osteoporosis. Despite these risks, the nurse aide proceeded with the transfer without seeking assistance or reporting the incident to the charge nurse. The resident later reported the fall to the Director of Rehabilitation and a Physical Therapist Assistant, who confirmed the injury and the improper use of the sliding board. Interviews with staff revealed that the nurse aide did not receive a shift report and was unaware of the resident's specific needs, including his missing leg. The Director of Nursing confirmed that the nurse aide had not been trained to use the sliding board and that the incident was considered a fall. The facility's policies and procedures for fall prevention and incident reporting were not followed, leading to the resident's injury and subsequent discharge from the facility.
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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 Big Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Lamun-lusk-sanchez Texas State Veterans Home | 4 mi | ★★★★★ | 0 | 0 |
| Focused Care At Hogan Park | 36.1 mi | ★★★★★ | 4 | 0 |
| Focused Care At Midland | 37 mi | ★★★★★ | 3 | 0 |
| Mitchell County Nursing And Rehabilitation Center | 37.4 mi | ★★★★★ | 9 | 0 |
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