Big Spring Center for Skilled Care

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 4 of 21 residents rooms reviewed for food safety (room [ROOM NUMBER]-1, 309-1, 311-1, and 316-1). 1. The facility did not have a system in place to assist residents in cleaning and maintaining their personal refrigerators to ensure safe food handling and prevent consumption of spoiled and/or expired foods.2. The facility did not have a system in place to ensure the refrigerators were monitored for internal Time Temperature Controlled for Safety cold foods were at 41 F or below. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments resident Pre-admission Screening and Resident Review (PASARR) to avoid duplicate test and effort for 1 of 24 residents (Resident #13) reviewed for PASARR screening, in that: Resident #13 did not have an accurate and updated PASARR Level 1 (PL1) assessment reflecting a diagnosis of mental illness. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1of 3 Residents (Resident #34) reviewed for incontinent care. CNA A failed to properly clean peri-area (pubis and vaginal area) and buttocks while providing incontinent care to Resident #34. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, 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 (Resident #34) reviewed for infection control. CNA A did not perform hand hygiene or gloves changes when providing incontinent care to Resident #34. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 5 residents (Resident #1, and #2) reviewed for abuse. A. The Former ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. B. The facility staff (CNA A, E, and LVN C) failed to follow the facility's abuse policy by not reporting the allegation of abuse to the Former ADM (Abuse Preventionist) regarding the Resident-to-Resident altercation (between Resident #1 and Resident #2) that occurred on 3/14/25. C. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide the resident and/or resident representative written notice which specified the duration of the bed-hold policy at the time of transfer of a resident for hospitalization for 2 of 5 residents (Resident #2 and #3) reviewed for transfers. The facility did not ensure Resident #2 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 2/08/25. The facility did not ensure Resident #3 and her representative were provided with a written bed-hold policy on the following dates when the resident was transferred from the facility: 3/17/25. This failure could place residents at risk of being improperly discharged and placed in unsafe conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 21 confidential residents. The facility failed to ensure 12 confidential residents were provided access to the Grievance form and provided the procedure for how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to store and date foods stored in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 3 residents (Resident #40 and Resident #51) and 3 of 6 staff (CNA E, CNA H, and CNA I) reviewed for infection control. 1. CNA E failed to follow policy and procedure for handwashing while providing incontinent care for Resident #40. 2. CNA H and CNA I failed to follow policy and procedure for handwashing while providing incontinent care for Resident #51. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #49) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses Post-Traumatic Stress Disorder were present upon Resident #49's admission date on 10/07/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment PASRR Evaluation, individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to ensure prompt efforts by the facility were made to resolve grievances for the residents for 1 of 6 residents (Resident #1) reviewed for grievances. A. The Social Worker failed to ensure a grievance was filled out and followed up on after Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. This failure could place residents at risk for decreased quality of life and feelings of neglect.

Inspectors wroteBased on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse. A. The Social Worker failed to follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 requested a room change and reported that she felt uncomfortable because of staff working in the facility. B. A confidential interview revealed that they did not follow the facility's abuse policy by not reporting the allegation/concern to the abuse preventionist when Resident #1 reported that she felt uncomfortable due to staff treatment from CNA A, CNA D, LVN E, and MA F on an unknown date. C. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 4 residents (Resident #1) reviewed for medication administration were free of significant medication errors. CMA A on [DATE] administered Resident #2's medications to Resident #1, which caused her blood pressure (BP) to decrease, and she was sent to the hospital. This failure could place residents at risk for receiving medications that were ordered for a different resident and could have possible adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's physician and representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition, in that: The facility failed to immediately notify the Physician (MD A) and Responsible Party (RP A) of a medication error that involved Resident #1 receiving resident#2's medication. This error cause Resident #1's blood pressure to decrease, to be administered and IV, and to be sent to the hospital. This failure placed residents at risk of not having physician (MD) and Responsible Party (RP) input and involvement in their care and treatment decisions.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards. NA A used a sliding board to transfer Resident #3 on a sliding board she had not been trained to use. This deficient practice could place residents transferred via sliding board at risk of falls which could result in injury and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had the right to be free from neglect for 2 of 5 residents (Resident #1, Resident #2), reviewed for neglect. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress.

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for 2 of 2 residents (Resident #1 and Resident #2) reviewed. CNA A neglected Resident #1 by failing to provide 1 person assistance and clocking out without informing the oncoming shift when she left Resident #1 alone in the facility shower room. CNA A neglected Resident #2 by failing to provide 1 person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of neglect, falls, mental anguish and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1, Resident #2) in that: CNA A failed to provide Resident #1 adequate supervision by failing to provide 1-person assistance when she clocked out without informing the oncoming shift she had left Resident #1 alone in the facility shower room. CNA A failed to provide resident #2 adequate supervision by failing to provide 1-person assistance when she left Resident #2 in a shower chair alone in his restroom shower area when she took Resident #1 to the shower room down the hall. This failure could affect all residents by placing them at risk of falls, lacerations, fractures and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received mail for 9 of 12 residents reviewed for rights to forms of communication for 1 of 1 facility reviewed for mail being delivered on Saturdays. The facility failed to: 1.) Ensure that mail had been delivered to all residents on all days that the United Postal Service delivered mail. This failure could result in a decline in the resident's psychosocial well-being and cause them to feel disconnected from family, friends, and current world issues.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 2 of 21 residents reviewed for unnecessary medication (Resident #69 and #123). The facility did not monitor Resident #69 for side effects of the anticoagulation medication Aspirin (blood thinning medication) or Enoxaparin Sodium Injection (a blood thinning medication). The facility did not monitor Resident #123 for side effects of the anticoagulation medication Warfarin (a blood thinning medication). These failures could place the residents at risk for adverse consequences of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 noon meals observed for puree. The facility failed to provide food that was in a form to meet resident needs for 2 of 2 meals observed (01/23/24 and 01/24/24). Foods were not pureed and had chuncks that still had to be chewed. These failures could place residents at risk of decreased food intake, choking and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services and 1 of 1 dining room observed, in that: 1. The facility failed to ensure foods were processed and pureed under sanitary conditions. 2. The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. 3. The facility staff failed to use proper infection control precautions by touching the top of open cups and bowls while serving meal trays during one of one dining observation. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, 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. 1. The facility staff failed to use proper infection control precautions by touching the top of open cups and bowls while serving meal trays during one of one dining observation. 2. The facility staff failed to wash their hands before medication administration to Residents #67 and #38. 3. The facility staff failed to use proper infection control precautions when providing incontinence care to Resident #1. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 2 residents with a urinary catheter (Resident # 17 and Resident #65); in that: 1. The facility failed to ensure catheter drainage bag was covered for privacy. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth

Inspectors wroteBased on interview and record review, the facility failed to recognize the residents right to formulate an advance directive for one of six residents (Resident #47) reviewed for Do Not Resuscitate (DNR) status. The facility failed to enter a do not resuscitate code status for Residents #47 in his chart between the dates of [DATE] to [DATE]. This failure could place residents at risk of not having their end of life wishes met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 1 of 1 residents with a urinary catheter (Resident #65); in that: 1. The facility failed to position the catheter collection bag and tubing in a manner to prevent infections. 2. The facility staff failed to use proper infection control precautions when proving foley care. These failures could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 4 medication carts (med cart on hall 300). CMA B had loose pills in the medication cart assigned to her on hall 300. Medication was identified as Atorvastatin 10 mg and belonging to Resident #17. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions .