The nursing assistant, identified as NA A in the inspection report, told investigators she had been trained to notify her chain of command when she observed anything abnormal. But when she found the skin irregularities on Resident #1, she made her own assessment that they didn't look suspicious.
"NA A stated she did not notify the charge nurse, treatment nurse, ADONs, nor DON as the skin irregularities were not suspicious and did not think it was that serious," inspectors wrote.
The nursing assistant couldn't determine the size of the discolorations and couldn't recall how the resident got them. When asked directly whether she should have reported what she found, she repeated that the irregularities didn't look suspicious and therefore didn't warrant notification.
She never considered how her decision might affect the resident's wellbeing.
The Director of Nursing wasn't notified about the skin irregularities until November 28, 2025. She immediately ordered a complete head-to-toe assessment and determined the marks came from the resident's wheelchair arm hitting a doorway.
But the delay meant no one with medical training had evaluated the injuries when they were first discovered.
"The DON stated once NA A observed Resident #1's skin irregularities, she should have immediately notified her charge nurse so that the charge nurse could accurately assess, document, and investigate the origin of the skin irregularities," the inspection report states.
The nursing assistant had received training on reporting changes in resident condition. Records show she completed a CNA proficiency competency audit in August that specifically educated her to "report all changes in condition promptly."
During her facility orientation, she attended an in-service on changes in condition and learned she was expected to notify supervisors when she observed anything abnormal.
Despite this training, she told inspectors the resident "never presented fearfully of staff nor residents" and the skin problems didn't seem serious enough to report.
The Director of Nursing conducted an immediate one-on-one retraining session with the nursing assistant after learning about the incident. She explained that assessing and making determinations about resident conditions falls outside a nursing assistant's scope of practice.
"The DON stated she had reeducated NA A that her scope of practice does not entail conducting an assessment or determination, and furthermore NA A's scope of practice is to notify immediately when she observes something abnormal," inspectors documented.
The nursing assistant will also complete online training modules about different types of skin irregularities as part of her corrective action.
The facility's own procedures require certified nursing assistants to report changes in condition promptly. The CNA Proficiency Audit procedure states that nursing assistants must report these changes immediately to their chain of command, which includes the charge nurse, assistant director of nursing, or director of nursing.
Federal inspectors cited The Premier SNF of Alice for failing to ensure the nursing assistant followed proper reporting protocols when she discovered the resident's skin injuries.
The Director of Nursing told inspectors that Resident #1's wellbeing was not compromised by the delayed reporting. But the incident highlighted how individual staff decisions to skip reporting procedures can prevent proper medical evaluation of potential injuries.
The violation occurred under federal regulations requiring nursing homes to ensure residents are free from abuse, neglect, and exploitation. While the specific harm was minimal in this case, the breakdown in communication protocols could have had more serious consequences with different types of injuries.
The nursing assistant's decision to conduct her own assessment rather than following established reporting procedures represents the type of individual judgment call that federal regulations are designed to prevent in institutional care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Premier Snf of Alice from 2025-11-29 including all violations, facility responses, and corrective action plans.