The Premier SNF Of Alice

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 8 residents (Resident #16 and Resident #110) reviewed for pharmacy services in that: The facility failed to notice the narcotic sheet count for Acetaminophen-Codeine (narcotic pain medication) for Resident #110 did not match the remaining number of tablets in the blister pack through 12 administrations of the medication on various dates and times.The facility failed to notice the narcotic sheet count for Acetaminophen-Codeine for Resident #110 did not match the remaining number of tablets in the blister pack when it was set for destruction and locked in the DON's office.The facility failed to document destruction of 1 tablet of Acetaminophen-Codeine properly on 12/03/25.The facility failed to document the time of administration of 1 tablet of Acetaminophen-Codeine to Resident #110 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the juicer's dispenser nozzle was clean. This failure could place residents at risk of foodborne illnesses. Findings included: During an observation of the kitchen on 04/22/26 at 10:25 a.m., the juicer's dispenser nozzle had a reddish slimy film in the middle of the nozzle and a hardened yellowish crust that had formed around the nozzle. During an interview on 04/22/26 at 10:27 a.m., [NAME] F said the juicer including the nozzle were cleaned every day. She said the juicer had been used earlier in the day, and that was probably why it was dirty. She tried to remove the yellowish crust but was not able. She could not say how not cleaning the juicer nozzle could negatively affect residents. During an interview on 04/24/26 at 9:35 a.m., DA E said it was the responsibility of all kitchen staff to ensure the kitchen was clean.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #83) residents reviewed for respiratory care. The facility failed to ensure Resident #83's oxygen was administered on 04/23/26 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #83's admission record, dated 04/23/26, reflected a [AGE] year-old female with an admission date of 02/07/25. Her relevant diagnoses included Alzheimer's disease (a progressive, irreversible neurodegenerative disorder), shortness of breath (the uncomfortable feeling of not getting enough air), and anxiety (mental health condition characterized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles 1 of 6 medication carts (Med Aide Cart 1) reviewed for storage. The facility failed to keep Med Aide Cart 1 locked when MA I stepped into room [ROOM NUMBER] to measure a resident's blood pressure during med pass at 7:51 AM on 04/23/26. The failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm.Findings included:During an observation at 7:51 AM on 04/23/26, Med Aide Cart 1 was unlocked in front of room [ROOM NUMBER]. MA I was inside room [ROOM NUMBER] measuring a resident's blood pressure for approximately 2 minutes, when she came back out of the room at 7:53 AM and noticed she left the medication cart unlocked. During an interview with MA I at 8:45 AM on 04/23/26, MA I stated she was supposed to keep the cart locked whenever she entered a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #101) of 3 residents. The facility failed to ensure Resident #101's facility death on [DATE], was accurately documented on his electronic medical record. This failure could place residents at risk of errors by staff when reading information in the clinical record that was inaccurate or incomplete.Findings included: Record review of Resident #101's admission record, dated [DATE], reflected an [AGE] year-old male with an admission date of [DATE] and a discharge date of [DATE]. His relevant diagnoses included chronic obstructive pulmonary disease (a progressive, irreversible lung disease causing restricted airflow and severe breathing difficulties), dementia (progressive decline in mental ability-including memory loss, confusion, and behavioral changes), and seizures (sudden, temporary busts of abnormal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of four residents reviewed for skin integrity.The facility failed to ensure on 11/27/2025, NA A failed to follow the facility's procedure when she observed Resident #1's left forearm with 3 brown and yellow skin irregularities. This failure could potentially negatively compromise a resident's well-being by prolonging warranted skin assessments and monitoring. The findings included: Record review of Resident #1's admission's record dated 11/28/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including severe protein calorie malnutrition, dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to maintain clinical records in accordance with accepted professional standards of practice, that were complete and accurately documented, for one resident (Resident #1) of three residents reviewed for skin assessments. The facility failed to ensure on 11/17/2025 around 9:00 p.m., LVN A failed to accurately document the description of three discolored dots on Resident #1's left forearm as well as light brown/purple bruise on the top of Resident #1's right forearm. This failure could place residents at risk of having incomplete and accurate records and not receiving appropriate treatment and services. The findings included: Record review of Resident #1's admission's record dated 11/28/2025 revealed Resident #1 was an [AGE] year-old female who was initially admitted on [DATE] and readmitted on [DATE]. Resident #1 was admitted with multiple diagnoses including severe protein calorie malnutrition, dementia (cognitive impairment), and surgical aftercare…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 5 CNAs (CNA A) reviewed for CNA certification. The facility failed to ensure CNA A's certification was current before allowing him to care for residents. CNA A worked in the facility providing resident care, on a full-time basis, with an expired certification during the period from [DATE] to [DATE]. This failure could place residents who received care from CNA A at a risk of decreased physical, mental, and psychosocial well-being.Findings included:Record review of CNA A's certification on [DATE] revealed the certification expired on [DATE]. In an interview with the DON at 12:16 PM on [DATE], the DON stated she was not aware CNA A's certification had expired. The DON stated each employee was responsible to ensure their license or certification was current. The DON stated HRC was responsible for reviewing the licenses and certifications of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 safely for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food. The facility failed to dispose of expired shelf stable and refrigerated food. The facility failed to ensure items were stored properly in a refrigerator instead of on a pantry shelf. The facility failed to ensure the large containers of cooking oil were free from cracks or holes and not leaking on the floor. The facility failed to maintain and assure all chemicals in the kitchen area were labeled appropriately. These failures could place residents at risk of foodborne illnesses, as well as place residents and staff at risk for falls and injuries. Findings were: Observations and initial tour of the kitchen on 2/3/25 at 8:10 AM revealed a half-used jug of lemon juice labeled as refrigerate after opening was being kept on a pantry shelf; a large container of cooking oil on a bottom shelf…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs, for 2 (Resident #5 and Resident #44) of 12 Residents reviewed for care plans in that: 1. The facility failed to implement a comprehensive person-centered care plan for Resident #5 to maintain the call light within reach of Resident #5. 2. The facility failed to ensure Resident #44's foley catheter ordered on 11/27/24 was care planned. This deficient practice could place residents at an increased risk of decline, and diminished quality of life. The findings included: 1. Record review of Resident #5's face sheet dated 02/03/25 revealed a [AGE] year-old male with an admission date of 01/20/20. Pertinent diagnoses included unspecified dementia, traumatic subdural hemorrhage (bleeding between the brain and the skull), and unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise the care plans for 1 of 5 residents (Resident #232) whose care plans were reviewed, in that: The facility failed to ensure Resident #232's care plan was revised to accurately reflect current urinary or foley catheter status. These failures could place residents at risk of receiving inadequate individualized care and services. Findings included: Record review of Resident #232's face sheet revealed an [AGE] year-old male with an admission date of 1/13/25. Record review of Resident #232's Comprehensive MDS dated [DATE] revealed Resident #232 was unable to respond or answer questions, or rarely or never understood, so the brief interview for mental status was not performed. MDS also reflected Resident #232 was dependent with toileting hygiene, oral hygiene, showering/bathing and dressing. Record review of Resident #232's care plan revealed resident was care planned for an indwelling catheter on 1/14/25, and it was revised on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan that included services to be furnished to attain or maintain the resident highest practicable well being for one resident (R#1) of 4 residents reviewed for skin care. A focus item of wound care treatment for Resident #1 was not listed on the care plan for over a month (from June to July). This failure could place Resident #1 at risk for lack of appropriate interventions and goals for the resident to meet their highest practicable level of care. This failure could lead to infection, progression of the growth, missing Dermatology and other specialty appointments and observations, and the excision of the growth. Findings were: Observation of Resident #1's wound care treatment with LVN #1 on 7/19/2024 at 1:46 p.m. This growth is softball sized with a rough textured surface. Wound care orders reviewed with LVN#1 and followed: clean area with wound cleanser and 4x4, pat dry, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 24 residents (Resident #20, Resident #49, Resident #36, Resident #40 and Resident #58), reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #20 (R#20) in that: -Care plan did not address R#20's dominant left sided weakness. The facility failed to implement a comprehensive person-centered care plan for Resident #49 (R#49) in that: -Care Plan was not updated in regard to his diet. The facility failed to implement a comprehensive person-centered care plan for Resident #36 (R #36) in that: -Care plan did not include the resident's sleep/wake preferences. The facility failed to implement a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to label and date items in the nutrition rooms 2. The facility failed to maintain cleanliness of the ice machine in the nutrition room 3. The facility failed to dry storage items sealed 4. The facility failed to keep personal items out of the prep area These failures could place residents at risk of foodborne illnesses. Findings include: Initial tour of the kitchen on 11/07/23 beginning at 10:55 AM with the DS revealed a 16 oz. bag of potato chips in the dry storage area that was open to air. There was a 12 oz. bag of powdered gravy in the dry storage area that was open to air. Observation of the kitchen and interview with the DS on 11/08/23 at 11:25 AM, revealed a large personal container of a clear beverage on the prep table next to the stove, that belonged to one of the cooks. The DS told her there were no personal drinks…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.