Big Spring Center for Skilled Care

In the surveyor’s words

From the most serious findings on record at Big Spring Center for Skilled Care, in the surveyor’s own words.

• Actual harm, isolatedF760May 14, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2021

  Based on observations, interviews, and record reviews, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens. 1. Foods stored in refrigerators, walk-in cooler, freezer were not labeled with item name and/or opened/use by date. 2. Foods stored in refrigerator, walk-in cooler, freezer were unsealed. 3. Temperature log for refrigerator, walk-in cooler, sanitizer dish washer did not have documentation that they were checked for 09/17/2021 through 09/19/2021. These failures place all residents that eat from the facility kitchen at risk for food borne illnesses. […]

• No harm, potential for more than minimal, patternF813Apr 24, 2026

  Based 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.Findings include:room [ROOM NUMBER]-1 During an observation on 4/22/26 at 10:34 AM, Resident… […]

• No harm, potential for more than minimal, patternF585Feb 27, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Feb 27, 2025

  Based 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. The findings included: The following observations were made on [DATE] at 09:58 AM during initial observation of the kitchen: Observed the following in the walk-in refrigerator: -Plastic container with mixed fruit open with no label and no date. -Metal bowl covered with tin foil with no label and no date. -Plastic container with lid open with label Taco Bake expired date ,d+[DATE]. […]