Health inspection·July 24, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings were: Observation of Resident #1's wound care treatment with LVN #1 on 7/19/2024 at 1:46 p.m. This growth is softball sized with a rough textured surface. Wound care orders reviewed with LVN#1 and followed: clean area with wound cleanser and 4x4, pat dry, and cover with bordered gauze once daily. Aseptic technique was maintained during wound treatment. Record review of Resident #1's face sheet dated 7/22/24 indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses of Dementia (disorder that affects a person's ability to perform everyday activities), Hypertension (high blood pressure), Depression, Anxiety, and Cerebral Infarction (a pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #1's annual MDS assessment dated [DATE] and a quarterly MDS assessment dated [DATE] indicated Resident #1 has a BIMS of unable to complete. MDS indicated this resident is not coherent enough to complete this form. MDS does not indicate any skin issues currently. A record review of a Nursing Home visit by Resident #1's physician dated 6/7/2024 stated Large golf-ball sized left neck mass. Necrotic in appearance. Record review of Resident #1's care plan updated 7/19/2024 revealed this resident has a growth to the neck. The care plan does not indicate when this growth was first noted by a physician. The care plan indicated the resident is at risk for infection and complications due to the resident itching and scratching the site. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676469 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 07/24/2024 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)