Premier Health Care Center

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and , for 4 of 16 residents (Resident #3, Resident #4, Resident #6, and Resident #43) reviewed for care plans. 1. The facility failed to ensure Resident #3's care plan objectives or goals were measurable. 2. The facility failed to ensure Resident #4's care plan objectives or goals were measurable. 3. The facility failed to ensure Resident #6's care plan objectives or goals were measurable. 4. The facility failed to ensure Resident #43's care plan objectives or goals were measurable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling catheter was not used unless there was valid medical justification for catheterization and that a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 3 of 16 residents (Resident #25, Resident #12, and Resident #49) reviewed for indwelling catheters. The facility failed to ensure that Resident #25 had a physician's order for an indwelling catheter and for monitoring and maintenance of an indwelling catheter. The facility failed to ensure that Resident #12 had a physician's order for an indwelling catheter and for monitoring and maintenance of an indwelling catheter. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Resident #25, Resident #5, and Resident #49) of 16 residents reviewed for respiratory care. The facility failed to ensure Resident #25's nebulizer (used to receive medications by breathing in mist through the mouth) for breathing treatment was properly stored when not in use and failed to ensure an oxygen sign was in place. The facility failed to ensure Resident #5's nebulizer for breathing treatment was properly stored when not in use and changed out weekly per orders. The facility failed to ensure Resident #49's nebulizer for breathing treatment was properly stored when not in use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater for 2 (Resident #34, and Resident #43) of 4 residents reviewed for medication administration. The facility failed to ensure the medication rate (10.34 %) was less than 5%. This failure placed residents at risk of incorrect doses of medications and optimal therapeutic response.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #34, #37, and #49) of 6 residents reviewed for infection control. LVN A failed to sanitize the shared glucometer before and after use on Resident #37 LVN B failed to sanitize the shared blood pressure cuff between Residents #34 and #49 and perform hand hygiene after touching residents during medication administration. This failure could affect residents and place them at risk for cross contamination and infections.

Inspectors wroteTag: F921/N4888 S/S=E Surveyor Name(s): Reisha Horn, RNImmediate Supervisor: [NAME], LBSWBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, comfortable, environment for residents, staff, and the public for 1 of 4 hallways reviewed, for physical environment. The facility failed to ensure the carpet was free of tears and stains in the back hallway on 05/20/2026. This failure place residents at risk of injury, and a diminished quality of life due to the lack of a well-kept and clean environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #43) whose assessments were reviewed for assessments. The facility failed to ensure Resident #43's quarterly MDS assessment did not correctly document the resident as having an unhealed pressure ulcer. This failure could place residents at risk for inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening residents diagnosed with mental illness were provided with a PASARR Level II Screening for 1 of 1 residents (Resident #16) reviewed for PASARR Level 1 screenings. The facility failed to correctly identify Resident #16 as having a mental illness and did not complete a new PASARR Level One Screening. This failure could place residents at risk of not receiving needed services and care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes needed t provide effective and person-centered care of the resident that meet professional standards of quality care and was developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #13) reviewed for base line care plan completion. The facility failed to include Resident # 13's catheter in the baseline care plan within the required 48-hour time limit. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 of 16 residents (Resident #43) reviewed for comprehensive care plans. The facility added an indwelling urinary catheter to Resident #43's care plan three days before receiving a verbal physician's order to place an indwelling urinary catheter. This failure could place residents at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for 1 (Resident #25) of 16 residents reviewed for unnecessary medications. The facility failed to have an adequate diagnosis and indication for the use of the medication Clonazepam for Resident #25. The facility failed to have an adequate diagnosis and indication for the use of the medication Diazepam for Resident #25. The facility failed to monitor the side effects of Clonazepam and Diazepam medications for Resident #25. These failures could place residents at risk for adverse consequences and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1, who was transported via the facility van, was secured with the proper utilization of the 5-seatbelt restraint system, required when transporting residents in a van, which resulted in injury and hospitalization on 01/08/2026. An Immediate Jeopardy (IJ) situation was identified on 01/13/2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an individual working in the facility as a nurse aide for more than 4 months, on a full-time basis was competent to provide nursing and nursing related services, completed a training and competency evaluation program approved by the State as meeting requirements and that individual was deemed or determined competent as provided for 5 of 9 nurse aides (NA-C, NA-F, NA-I, NA-K, and NA-L) reviewed for nursing services. The facility failed to ensure NA-C, NA-F, NA-I, NA-K, and NA-L were certified within 4 months of being hired. This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was not known.

Inspectors wroteBased on observation and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition of 1 of 1 van reviewed. The facility failed to ensure the facility van was maintained. This failure could place residents at risk of injury due to not being supervised and placed them at risk of serious bodily harm, physical impairment, hospitalization or death.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage. The facility failed to ensure foods were sealed and/or labeled properly in dry storage. This failure could place residents at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practice, that were complete and accurate for 1 of 8 (Resident #10) residents reviewed for resident records. The facility failed to ensure Resident #10's physician orders were accurate and reflected Resident #10's current hospice. This failure could place residents at risk of having errors with their care and treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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, which must include, at a minimum, standard and transmission-based precautions to be followed to prevent spread of infections, for 7 of 41residents reviewed (Resident #4, Resident #11, Resident #15, Resident #28, Resident #191, Resident #192, and Resident #241) for infection control and prevention. 1. The facility failed to ensure Resident #4 had EBP (Enhanced Barrier Precautions) signage and PPE (Personal Protective Equipment) available for staff providing care due to Resident #4's suprapubic urinary catheter. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessmen of diagnosis of Diebeates Mellitus, Goutt for 1 of 16 residents reviewed (Resident #34) residents reviewed for comprehensive care plans. The facility failed to implement care plan for Resident #34 that included Diabetes Mellitus and Gout These failures could place residents at risk of not having preferences and needed care for residents.

Inspectors wroteBased on interview and record review, the facility failed to revise the resident's care plan for use of firgure eight binder and recent fall. 1 of 16 residents (Resident #33) reviewed for comprehensive care plans. The IDT team failed to revise Resident #33's care plan to include the updated fall with injury, left distal clavicle fracture and physician order for figure eight binder.(Clavicle support brace). These failures could affect residents by placing them at risk of not having their individual needs 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 one of two residents (Resident #28) reviewed for catheter care. The facility failed to ensure Resident #28's indwelling urinary catheter collection bag was secured off the floor. This failure placed residents at risk for infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 3 of 10 (Resident #4, Resident #13, and Resident #17) reviewed for respiratory care. The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #4, Resident #13, and Resident #17 doors. This failure could place residents at risk of staff and visitors not aware when a resident is utilizing oxygen.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 3 (Resident #7, #25 and #27) of 5 residents whose assessments were reviewed. The facility failed to ensure residents' MDS assessments accurately reflected the use of bed rails. These failures placed the residents at risk for unmet care needs and/or decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 4 (Resident #8, Resident #13, Resident #23, and Resident #83) of 4 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #8, Resident #13, Resident #23, and Resident #83. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 3 of 5 residents (Resident #7, Resident #25, and Resident #27) reviewed for bed rails. The facility failed to ensure Resident #7, Resident #25, and Resident #27 had assessments and/or informed consents for the use of bed rails. This failure could place the residents at risk for entrapment, injury, or harm.

Inspectors wroteBased on observations and interviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure that staff sanitized the thermometer while taking temperature of food. 2. The facility failed to dispose of expired foods. 3. The facility failed to ensure foods were labeled properly in refrigerators. 4. The facility failed to ensure staff used proper hand hygiene. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.