The Premier SNF of Alice

Inspectors wroteBased 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. [...]

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 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

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 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.