Healthcare Facility Inspection of the VA West Texas Healthcare System in Big Spring

VA Office of Inspector General · Report 26-00040-285 · October 2, 2026 · Office of Healthcare Inspections

What the OIG found

OIG conducted a focused Healthcare Facility Inspection of the West Texas system in Big Spring, evaluating care across five domains: culture, environment of care, patient safety, integrated veteran care, and the veteran-centered safety net. The inspection produced five recommendations in two domains. In environment of care, staff were not consistently following the facility’s Legionella prevention plan for the community living center, including testing, documentation, and mitigation requirements under VHA Directive 1061(4). In patient safety, the facility lacked a written policy and service-level workflows for communicating test results aligned with VHA Directive 1088(1), had not taken corrective action on unfavorable trends in test-result communication, and its Healthcare Delivery Board was not providing proper oversight of clinical care quality. OIG recommended the Director enforce the Legionella plan and evaluate the board’s oversight, and that the Chief of Staff and Associate Director for Patient Care Services write the test-result policy and workflows and act on the negative communication trends.

Who it concerns

VA West Texas Healthcare System in Big Spring

Why it matters to a family

For families, two findings matter most: whether abnormal test results are actually communicated under a written policy with named staff roles, and whether the community living center’s water is managed to protect residents from Legionella.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →