Inspection·November 9, 2023

F 0656 Findings included: Level of Harm - Minimal harm or potential for actual harm 1.) Record review of Resident # 20's face sheet documented a [AGE] year-old female with an original admission date of 04/26/21 and a re-entry date of 04/17/22. Diagnoses included a stroke with paralysis and weakness affecting the left non-dominant side, diabetes, depression, anxiety, high blood pressure, heart failure, reflux, and lung disease. Residents Affected - Some Record review of R #20's MDS dated [DATE] revealed R #20 had a BIMS of 15 indicating cognitively intact, was left-handed, required 1 person assistance with ADL's, and was able to feed herself with adaptive equipment. Record review of R #20's comprehensive care plan dated 05/20/2021 documented R #20 had left sided hemiplegia (paralyzed) but did not address anything about R #20 having been left hand dominant, or resident centered focus, goals, and interventions for activities. Record review of R #20's [NAME] did not address anything about R #20 having been left hand dominant, resident centered focus, goals, or activities. Interview with the AD on 11/09/23 at 10:32 AM stated R #20 only liked to play bingo or [NAME]. The AD stated she encourages R #20 to do what she likes to do. The AD stated she tells her residents it's good exercise for their fingers. The AD did not know if anything was being done to address the resident's left dominant paralysis and was unaware R #20 was left-handed. Interview with the DOR on 11/09/23 at 10:38 AM stated R #20 was on Occupational Therapy (OT) services which she got every 3 months and had started OT on 10/29/23. Prior to that, she came off skilled services on 01/10/23. The DOR stated R #20 told her she wanted to start signing her name on Tuesday, 11/07/23, and that was the first time she had mentioned wanting to do something. The DOR stated R #20 had ROM in her left shoulder and much less in her left fingers. The DOR stated there had not been much progress because R #20 had come from another facility and there were a few years since her stroke and R #20 was not motivated to rehab. The DOR stated when they picked up R #20 here, she wanted to participate and get up out of bed. The DOR stated R #20 wanted to go home but family member said no-she needs too much care for them to handle. The DOR stated adaptive equipment should be care planned. The DOR did not know if the resident could hold or activate the call light with her left hand. The DOR stated she could not find anything about adaptive equipment in the orders or the care plan, as she scoured the electronic medical record. The DOR stated there should be something addressing R #20's left dominant paralysis, other than the hemiplegia and requiring assistance from staff. The DOR stated R #20 had a nosey cup and a plate guard. The DOR stated R #20 took her meals in her room because she spilled a lot. Interview with the MDS Coordinator on 11/09/23 at 01:07 PM stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there were changes in resident care. Interview with the DON on 11/09/23 at 02:15 PM, stated care plans were done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The [NAME] stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings were conducted with staff, resident changes were discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #20 would be, direct care staff would not know to make sure the call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 2 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light was properly positioned, or her food tray was set up properly. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #20, #49, and #36's care plans were updated, and the care plan updates were just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Record review of R #49's face sheet documented a [AGE] year-old male with an original admission date of 04/02/20 and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated R #36's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 3 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. Record review of R #49's face sheet documented a [AGE] year-old male with an original admission date of 04/02/20 and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated the resident's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. 2.) Record review of Resident #40's face sheet dated 11/09/2023 documented an [AGE] year-old male (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 4 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with an initial admission date of 7/1/2022 and a readmission date of 7/3/2023. Diagnoses include Cerebral Infarction (type of stoke caused by impaired blood flow to the brain), Type 2 Diabetes (insufficient production of insulin in the body), Hypertension (high blood pressure), Stage 4 pressure ulcer (deep wound that exposes underlying muscle, tendon, cartilage or bone), right leg above knee amputation, Dysphasia (difficulty swallowing), Heart Failure, and Gastronomy (an opening in the stomach from the abdominal wall made surgically for the introduction of food). Record review of R #40's MDS dated [DATE] revealed R #40 had a BIMS of 3 (Severe Impairment), had a feeding tube, and required extensive assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Record review of R #40's comprehensive care plan dated 7/5/2022 documented R #40 had pleasure feedings of purred with nectar liquids. Record review of R #40's physician orders dated 7/3/2023 documented R #40 had enteral feedings and pureed texture, nectar consistency diet. Record review of R #40's nursing documentation dated 10/12/2023 documented resident's (R #40) spouse was feeding resident a sandwich. educated her on his diet. notified RP. RP stated that they have been giving him tacos once in a while. Interview on 11/09/23 at 01:01 PM, the DON stated R #40's family had brought in regular food that contradicted with R # 40's MD dietary orders. The DON stated the MDS Coordinator did care plans for residents and should have been care planned and updated when the change had occurred. Interview on 11/09/23 at 01:05 PM, the ADON printed out R #40's care plan, dated 11/9/2023, that reflected, family occasionally brings outside food to resident (R #40). This surveyor informed ADON that previous care plan for R #40 was saved on 9/9/2023 at 9:24 AM. by this surveyor and did not reflect the changes on the care plan. The ADON stated that she was not sure what the previous care plan for R #40 documented since current care plan does reflect the change. Interview on 11/09/23 at 01:07 PM, the MDS Coordinator stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there are changes in resident care. Interview on 11/09/23 at 02:15 PM, the DON stated care plans are done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The [NAME] stated staff utilized a 24-hour communication binder located at each nursing station that is utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #40 would be, direct care staff would not know that family was bringing in outside food to R # 40 and staff would not know to monitor R #40's for any changed condition if outside food was eaten. The DON stated she is responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #40's care plan was updated, and R #40's care plan update was just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. 3.) Record review for R #58's admission record dated 11/7/23 revealed R #58 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 5 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility initially on 09/20/2023, was a [AGE] year-old male. R #58's diagnoses included unspecified protien-calorie malnutrition , Parkinson's (degenerative disorder of the central nervous system that mainly affects the motor system), Pneumonia due to inhalation of other solids and liquids, lack of coordination, and history of falls. Record review of R #58's care plan dated 10/05/23 indicated R #58 was changed to a NPO diet, NPO texture, NPO consistency however the care plan was not updated to implement that the resident could no longer receive food or fluids other than enteral feed. The care plan stated that R #58 could have a snack and it was encouraged to offer the resident drinks to maintain hydration. Observation on 11/7/2023 at 10:35 PM of R #58 in his room. R #58 was in his bed and had just finished physical therapy. R #58 noted with no drinks or food in sight. R #58 appeared calm, with pale skin. R #58 was nonverbal and could not express whether he was able to eat or drink anything or what was acceptable in his diet. This surveyor observed R #58 receiving an enteral feeding. Interview with CNA A and CNA B stated they were working the 500 hall on 11/8/23 at 2:08 PM. CNA A and CNA B stated they were not sure of the diet for R #58. This surveyor asked how do they know what R #58 can or cannot eat. CNA A and CNA B stated the charge nurse was the one that fed R #58 and they believed R #58 was fed only through R #58's g-tube but may be able to be pleasure fed. This surveyor asked CNA A and CNA B what could happen if they gave the R #58 food or drink because they were not sure of the R #58's diet. CNA A and CNA B stated R #58 could become very sick or even die if R #58 choked. Interview with the charge nurse for the assigned floor was on 11/8/23 at 2:32 PM, stated R #58's diet was an NPO diet and they had not changed it on R #58's care plan because R # 58's family member was not accepting of the diet change. This surveyor asked the LVN A where in the Care Plan can I find that R #58's family member had not been accepting of the diet and reason for not updating the plan? LVN A could not give this surveyor an answer. LVN A stated, I don't know. This surveyor asked if there was a reason why CNA A and CNA B did not know what the diet was for R #58. LVN A stated that CNA A and CNA B did not know R #58's diet and CNA A and CNA B could have simply gone to the [NAME] to verify, but CNA A and CNA B may have been nervous to answer or say they needed to check. Interview with the DON on 11/9/23 at 2:30 PM, revealed care plans began upon admission, quarterly, and updated as needed. The DON stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #58 would be that direct care staff could had given R #58 food or something to drink by accident because the care plan stated that it was encouraged. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if R #58's care plan had been updated recently. The DON stated, moving forward, daily audits of care plans would be conducted. The DON stated she would make sure direct care staff would be utilizing the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Review of Care Planning Policy not dated states: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 6 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will; Residents Affected - Some a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. Record review of facility Comprehensive Care Planning Policy not dated stated; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goal, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representatives, if applicable, so that changes can be reflected in the comprehensive care plan. A comprehensive care plan will beDeveloped with 7 days after completion of the comprehensive assessment The resident's care plan will be reviewed after each Admission, Quarterly, Annually and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 7 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 allowed in the kitchen area due to the risk of cross contamination. Observation of the east wing nutrition room on 11/09/23 at 2:00 PM, revealed 4, 14 oz. containers of pudding expired 09/14/23, 1, 7.23 oz. bag of chocolate rice cakes expired 11/01/23, 1, 7.5 oz. bag of sugar free candies expired 05/01/23, 2, 7.5 oz. bag of sugar free candies expired 11/01/23, 1, 2 oz. opened, half empty and unlabeled bag of cheese flavored snacks. The ice machine had a thick, white cheesy substance on the ice chute. Interview with the cook on 11/08/23 at 11:25 AM, revealed having her cup in the prep area was not allowed and it just slipped her mind. The cook stated personal items were not allowed in the prep areas because cross-contamination could occur from touching the item, then touching something in the kitchen used to prepare food for the residents. It could make the resident sick. Interview with the DS on 11/09/23 at 2:10 PM, revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676469 If continuation sheet Page 8 of 9 Printed: 05/15/2026 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 676469 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the DON on 11/09/23 at 2:14 p.m., revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. A record review of in-services and training for the kitchen staff revealed 05/07/23 covered correct serving spoons, 05/12/23 tardiness, 06/03/23 handwashing, 07/26/23 dress code/jewelry, 08/26/23 harassment/cell phone use, 08/29/23 code of conduct, 09/22/23 professionalism/code of conduct, 10/01/23 handwashing, 10/15/23 legionella. Event ID: Facility ID: 676469 If continuation sheet Page 9 of 9