The Premier Snf Of Alice

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated while she inspected the skin she inquired if Resident #1 knew the origin of the discoloration of skin irregularities, to which Resident #1 could not recall. NA A stated the 3 discolorations were brown and yellow but could not determine circumference nor diameter of the irregularities, however stated they did not 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. NA A stated Resident #1 never presented fearfull of staff nor residents. When NA A was asked if she should have notified the charge nurse when she saw the skin irregularities, NA A reiterated the skin irregularities did not look suspicious and therefore did not think it was serious and did not warrant any notification to the charge nurse. NA A did not verbalize how her inaction to notify her chain of command could have affected Resident #1's well-being. NA

A stated she had attended the facility's change in condition in-service as part of her orientation and recalled being educated that she is expected to notify her chain of command when she observes anything abnormal, however NA A reiterated the skin irregularities were not suspicious, Resident #1 never presented fearfully or scared of any person. During an interview on 11/29/2025 at 3:06 p.m., the DON stated she was notified of Resident #1's skin irregularities on 11/28/2025 and immediately directed the treatment nurse to perform a thorough head to toe assessment on Resident #1 and concluded the left arm skin irregularities stemmed from Resident #1's wheelchair arm placement when Resident #1 was attempting to pass through

a doorway. 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 DON stated Resident #1's well-being was not compromised, and reiterated NA A should have notified the charge nurse once she saw something abnormal to Resident #1 in congruence with the facility's procedures. 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. The DON stated she conducted an impromptu one-to-one in-service with NA A and re-educated her that if she was to notice anything abnormal on any resident, she is to immediately notify her chain of command, which includes the charge nurse, ADON, or DON. The DON stated NA A will also be tasked with several on-line training modules that will re-educate NA A on the different types of skin irregularities. Record review of the CNA proficiency competency audit dated 08/22/2025 revealed CNA A was educated to report all changes

in condition promptly. Record review of the facility's C.N.A. Proficiency Audit procedure undated revealed C.N.As are to report changes in condition promptly.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Premier Snf of Alice

800-A Coyote Trail Alice, TX 78332

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

findings as part of the facility's protocol. The DON stated the reason she should have documented the skin assessment on 11/17/2025 was to ensure accurate monitoring of the skin irregularities to prevent any further progression of any compromising skin integrity issue. The DON stated Resident #1's well-being was not compromised as the skin irregularities had resolved with no evidence of any malice intent. The DON stated the discoloration could have stemmed from when Resident #1 attempts to pass through doorways with her wheelchair. The DON stated going forward, the facility has planned to conduct an as needed in-service regarding documenting skin assessment. Record review of the facility's Skin Assessment undated revealed 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission.The assessment may also be performed after a change in condition or after any newly identified pressure injury. h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. 7. Documentation of skin assessment: b.

Document observations (e.g. skin conditions.).

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