Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Premier Snf Of Alice during CMS and state inspections, most recent first.
Controlled-substance records were not kept accurately for one resident’s Acetaminophen-Codeine, with a mismatch between the narcotic sheet and the blister pack, undocumented destruction of a tablet, and an undocumented administration. In addition, another resident with dementia and anxiety did not receive the full ordered dose of topical Ativan; staff gave only half of the prescribed amount while the MAR still reflected administration as ordered. The DON and nursing staff acknowledged the documentation and dosing problems.
Unclean Juicer Nozzle in Kitchen: Kitchen observation found the juicer dispenser nozzle had a reddish slimy film and hardened yellowish crust. A dietary staff member said the juicer and nozzle were cleaned daily but had been used earlier that day, and she could not remove the buildup. The DA said she had not left the nozzle soaking in water overnight as required, and the DM said she had not been checking the nozzle closely enough. Facility records showed dietary staff were assigned to clean the juicer daily.
Oxygen Delivered at Incorrect Setting: A resident with Alzheimer's disease, shortness of breath, and anxiety had an order for O2 at 2 LPM via nasal cannula, but staff observed the concentrator set at 2.5 LPM while the resident was awake in bed. An LPN later confirmed the incorrect setting and stated she had not yet checked the resident after her shift began, while the DON said nursing staff were responsible for ensuring oxygen settings matched the order.
Unlocked Medication Cart During Med Pass: Med Aide Cart 1 was observed unlocked outside a resident room while an MA was inside checking a resident’s BP during med pass. The MA stated she was supposed to keep the cart locked whenever entering a resident room, and the DON stated med aides and nurses should lock carts before entering rooms to check BP or administer meds. Facility policy stated medication carts must be locked or attended to by authorized staff.
Incomplete Documentation of Resident Death: A resident with COPD, dementia, seizures, and a DNR order died in the facility, but the EMR did not include documentation of the expiration or the actions taken at the time of death. The death notice showed the remains were released to a mortuary, and the DON and an LVN stated nursing staff were responsible for documenting how the resident was found, vital signs, code status, assessments, notifications, time of death, and release of the body.
A nurse aide observed skin discolorations on a resident's forearm but did not notify the charge nurse as required by facility policy, believing the findings were not serious. The resident, who had multiple health conditions and was at risk for skin breakdown, had no prior documentation of such irregularities. Later, five skin irregularities were found and the DON confirmed that immediate reporting was necessary for proper assessment.
A nurse failed to document observed skin discoloration and bruising on a resident during a skin assessment, despite facility protocols requiring such documentation. Although the findings were verbally reported to the DON, the absence of written documentation resulted in incomplete and inaccurate clinical records for a resident with multiple health conditions and a care plan for skin integrity.
A CNA provided resident care with an expired certification after both the DON and HRC failed to identify the lapse during routine audits. The CNA was unaware of the expiration, believing his certification would be automatically renewed, despite facility policy requiring staff to maintain and submit current credentials.
The facility failed to maintain proper food storage and chemical labeling standards, leading to potential health risks. Observations revealed expired and improperly stored food, unlabeled chemicals, and a leaking oil container. Interviews with staff and administration highlighted the lack of clear policies and the Dietary Manager's responsibility for kitchen safety.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care. A resident's call light was not consistently within reach, and another resident's foley catheter care was not documented in the care plan. Staff interviews confirmed these oversights, highlighting the need for accurate and up-to-date care plans.
A facility failed to update a resident's care plan to reflect the discontinuation of a Foley catheter, despite physician orders and a revision of the care plan. The resident was admitted with a catheter, which was removed shortly after admission, but the care plan continued to list catheter-related interventions. This oversight was identified through record reviews and staff interviews, highlighting a lapse in adhering to the facility's policy for updating care plans based on changing needs.
A resident with a history of dementia and other conditions had a large necrotic growth on the neck that was not included in the care plan for over a month. Despite having wound care orders, the care plan lacked documentation of necessary interventions and goals. Facility staff acknowledged the oversight, noting that the resident could have been placed on a wound care doctor's list, but this was not done.
Controlled Medication Counts and Ordered Dosing Were Not Followed
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for two residents reviewed for pharmacy services. For one resident with pain and moderate cognitive impairment, the facility did not maintain an accurate controlled-substance count for Acetaminophen-Codeine. The narcotic sheet showed 28 tablets received and 16 tablets remaining after the last documented administration, but when the blister pack was later observed in the DON’s office, it contained 14 tablets. The DON stated the count should have matched before the medication was placed in the locked drawer and acknowledged that two tablets were unaccounted for. The record and staff interviews showed that on one occasion a tablet was popped from the blister pack, dropped, and destroyed, but the destruction was not documented on the narcotic sheet. The same event also involved another tablet being administered to the resident without documentation on the narcotic sheet. The DON stated the medication was then administered 12 more times without any nurse reporting that the count was off between the narcotic sheet and the blister pack. RN G and LVN H both stated they participated in the destruction and administration events but did not sign the narcotic book as required. For another resident with dementia with behavioral disturbances and anxiety, the facility did not administer Ativan as ordered. The physician order was for Ativan 1 mg/2 mL every 8 hours topically to the wrist, but the MAR showed the medication as administered every 8 hours while the controlled count sheets reflected only one 0.5 mg/1 mL syringe being given each time. Observation of the med cart showed two bags of prefilled syringes, and the combined syringes totaled 17 prefilled syringes. An LVN stated the resident had been receiving only half of the ordered dose, and the DON confirmed the resident was supposed to receive 1 mg/2 mL but had only been getting 0.5 mg/1 mL every 8 hours.
Unclean Juicer Nozzle in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when the juicer's dispenser nozzle was found unclean during kitchen observation. On 04/22/26 at 10:25 a.m., the nozzle had a reddish slimy film in the middle and a hardened yellowish crust around it. During the same observation, the dietary staff member said the juicer, including the nozzle, was cleaned every day and stated the juicer had been used earlier that day, which was why it was dirty. She attempted to remove the yellowish crust but was unable to do so. During later interviews, the dietary aide stated that kitchen staff were responsible for cleaning assigned areas at the end of each shift and that dietary aides were responsible for cleaning the juicer and nozzle daily. She said she cleaned the juicer daily but had failed to leave the nozzle soaking in water as required. The dietary manager stated she was responsible for ensuring the kitchen was clean, that all kitchen staff were assigned to clean appliances daily, and that the juicer nozzle was supposed to be left soaking in water overnight. Record review showed the facility's cleaning schedule assigned the juicer to dietary staff for the prior two weeks, and the facility's cleaning policy stated that all employees were responsible for following the cleaning schedule and that the DSM was responsible for ensuring tasks were completed thoroughly.
Oxygen Delivered at Incorrect Setting
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #83 by not providing oxygen at the physician-ordered setting. Resident #83 was a [AGE]-year-old female admitted on 02/07/25 with diagnoses including Alzheimer's disease, shortness of breath, and anxiety. Her annual MDS assessment dated 02/20/26 reflected a blank BIMS score, indicating severely impaired cognition. Her quarterly care plan dated 04/22/26 identified oxygen therapy for ineffective gas exchange and directed oxygen at 2 LPM via nasal cannula, and the physician order dated 04/23/26 specified oxygen at 2 LPM via nasal cannula every shift related to shortness of breath. During observation on 04/23/26, Resident #83 was lying in bed awake with a nasal cannula in place, and the oxygen concentrator was set at 2.5 LPM instead of the ordered 2 LPM. An LVN later confirmed the concentrator was set at 2.5 LPM and stated she had not yet checked on the resident since her shift began at 6:00 a.m. The LVN reviewed the electronic record and identified the resident's oxygen order as 2 LPM continuously via nasal cannula. The DON stated it was nursing staff's responsibility to ensure oxygen settings matched the order and that staff were supposed to check oxygen settings each time they entered a resident's room.
Unlocked Medication Cart During Med Pass
Penalty
Summary
Med Aide Cart 1 was observed unlocked in front of a resident room while MA I was inside the room measuring a resident’s blood pressure during med pass. The cart remained unattended for approximately 2 minutes until MA I returned from the room and noticed it had been left unlocked. During interview, MA I stated she was supposed to keep the cart locked whenever she entered a resident’s room to check blood pressure or administer medications, and that an unlocked, unsupervised cart could allow another resident or visitor to open it and take medication. During interview, the DON stated med aides and nurses should lock their carts before entering a resident’s room to check blood pressure or administer medications, and that carts should be kept locked when not supervised to prevent unauthorized access to medications. Record review of the facility policy titled Medication Storage in the Facility stated that only licensed nurses, the Consultant Pharmacist, and other lawfully authorized staff are allowed unsupervised access to medications, and that medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.
Incomplete Documentation of Resident Death
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #101 by not documenting the resident’s death in the electronic medical record. Resident #101 was an [AGE]-year-old male admitted with diagnoses including COPD, dementia, and seizures. His admission MDS reflected a BIMS score of 06, indicating severely impaired cognition, and his care plan reflected a DNR order with interventions stating that CPR would not be initiated in the absence of blood pressure, pulse, and respirations. The death in facility MDS reflected that the resident was deceased, but the progress notes showed the last entry was made on [DATE] and there was no documentation describing the resident’s expiration or the actions taken when he died. The Death Notice indicated the resident’s remains were released to a local mortuary at 10:29 p.m. and was signed by a Hospice Nurse. During interview, the LVN and DON stated that when a resident expires in the facility, nursing staff are responsible for documenting how the resident was found, who found them, the presence or absence of vital signs, code status, assessments and actions taken, who was notified, the time of death, and to whom the body was released. The facility’s Pronouncement of Death policy required the nurse to notify the attending physician and document the date, time, and physician’s statement at notification, and the Documentation policy required complete, accurate, and timely documentation.
Failure to Report Skin Irregularities Observed by Nurse Aide
Penalty
Summary
A nurse aide failed to follow facility procedures when she observed three brown and yellow skin irregularities on a resident's left forearm during morning care. The aide did not notify the charge nurse or other nursing leadership, as required by facility policy, because she did not consider the irregularities to be suspicious or serious. The aide had previously received training on reporting abnormal findings but did not act in accordance with this training. The resident involved was an elderly female with multiple diagnoses, including severe protein calorie malnutrition, dementia, and recent digestive system surgery. Her care plan identified her as being at risk for pressure ulcers and required staff to notify nursing leadership immediately of any new skin breakdown, including discoloration, blisters, or bruises. Prior weekly skin assessments and progress notes did not document any skin irregularities, and there was no record of the aide's observation in the resident's medical record. Upon later observation by surveyors, five skin irregularities were found on the resident's left forearm, including areas of red and dark purple discoloration. The resident was unable to recall the origin of the marks and did not report pain or distress. The Director of Nursing confirmed that the aide should have reported the findings immediately, as per facility policy, to allow for timely assessment and documentation by nursing staff.
Failure to Document Skin Assessment Findings
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document observed skin irregularities on a resident during an assessment. On the evening in question, both the LVN and a certified nursing assistant (CNA) observed discoloration and bruising on the resident's forearms while providing enteral nutrition. The CNA described a yellowish-brown bruise-like discoloration on the right forearm and the LVN noted a light brownish/light purple bruise on the right forearm and two small dots on the left forearm. Although the LVN reported the findings to the Director of Nursing (DON), she did not document the observations in the resident's clinical record as required by facility protocol and accepted professional standards. Record reviews showed that the resident's weekly skin assessments and progress notes did not reflect the skin irregularities observed on the specified date. The resident had a history of severe protein calorie malnutrition, dementia, and surgical aftercare, and was care planned for potential pressure ulcer development with instructions for staff to document any new skin issues. The lack of documentation meant that the resident's clinical record was incomplete and not accurately maintained, which is a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failure to Ensure CNA Maintained Current Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained a current certification in accordance with state laws before allowing him to provide resident care. Record review showed that the CNA's certification had expired, yet he continued to work full-time providing care to residents during the period in question. The Director of Nursing (DON) was unaware of the expired certification and stated that it was the responsibility of each employee to keep their license or certification current, while the Human Resources Coordinator (HRC) was responsible for periodically reviewing and auditing staff credentials. The HRC acknowledged missing the expired certification during her last audit. Interviews revealed that the CNA was not aware his certification had expired, believing that continued employment would result in automatic renewal and that the facility would maintain his certification. The facility's Employee Handbook required all licensed, registered, or certified staff to maintain current credentials and submit documentation to their department head, with failure to do so potentially resulting in suspension or termination. The CNA had signed and acknowledged receipt of this policy.
Deficiencies in Food Storage and Chemical Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and sanitation, as observed during a survey of the kitchen. Several issues were identified, including improperly labeled and expired food items, as well as food stored in incorrect locations. Specifically, a half-used jug of lemon juice requiring refrigeration was found on a pantry shelf, and a large container of cooking oil was leaking onto the floor. Additionally, an opened meat product was thawing in bloody water past its expiration date, and several Ziploc bags of dry goods were also past their expiration dates. The survey also revealed that chemicals in the kitchen were not labeled appropriately, posing a risk to both residents and staff. A large spray bottle containing a strong-smelling yellow liquid was found without any label, which was later identified as Clorox cleaner by the Dietary Manager. Interviews with staff, including the Dietary Manager and housekeeping, highlighted the lack of proper labeling practices and the potential hazards of unlabeled chemicals, such as accidental misuse or ingestion by residents. Interviews with the facility's administration and staff indicated a lack of clear policies regarding the labeling and disposal of chemicals and expired food. The Dietary Manager was identified as ultimately responsible for ensuring proper labeling and disposal practices in the kitchen. The absence of a specific policy for labeling chemicals was noted, despite verbal instructions to staff to label them. The Administrator and Director of Nursing acknowledged the risks associated with serving expired food and improper storage, emphasizing the Dietary Manager's responsibility for maintaining kitchen safety and sanitation.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For Resident #5, the facility did not ensure that the call light was consistently within reach, despite the resident's dependence on staff for all activities and impaired communication due to cognitive issues. Observations revealed that the call light was repeatedly placed out of reach, and staff interviews confirmed that this was sometimes done intentionally to prevent the resident from swinging it around. However, this practice was not documented in the care plan, and the Director of Nursing (DON) was unaware of any such issues. For Resident #44, the facility did not include the care of a foley catheter in the resident's care plan, despite an order for its use due to obstructive and reflux uropathy. The resident's medical records indicated the presence of an indwelling catheter, but the care plan lacked any mention of foley care. Interviews with staff, including an LVN and the MDS Coordinator, confirmed the oversight and acknowledged the importance of having such care documented to monitor for potential infections and ensure proper care. The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans that include measurable objectives and timeframes to meet residents' needs. However, the care plans for Residents #5 and #44 were not updated to reflect their current needs, leading to potential risks for the residents' quality of life. The DON and staff recognized the importance of accurate and up-to-date care plans but admitted that these deficiencies were overlooked.
Failure to Update Resident's Care Plan for Foley Catheter Status
Penalty
Summary
The facility failed to update and revise the care plan for a resident to accurately reflect the current urinary or Foley catheter status. The resident, an elderly male, was admitted with a Foley catheter, which was discontinued shortly after admission as per physician orders. However, the care plan continued to list the resident as having an indwelling catheter with interventions to meet urinary and catheter goals, even after a revision was made. This oversight was identified during a review of the resident's care plan and physician orders, as well as through interviews with the resident's family and facility staff. Observations and interviews revealed that the resident no longer had a Foley catheter, and the care plan should have been updated to reflect this change. The Director of Nursing (DON) acknowledged that the catheter and urinary status should have been removed from the care plan following the discontinuation order. The facility's policy requires that care plans be reviewed and revised based on changing needs and interventions, but this was not adhered to in this case, potentially placing the resident at risk of receiving inadequate individualized care.
Failure to Include Skin Condition in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a significant skin condition. The resident, who has a history of dementia, hypertension, depression, anxiety, and cerebral infarction, was observed to have a large, necrotic growth on the neck. Despite the presence of wound care orders, the care plan did not include this condition for over a month, from June to July. This omission in the care plan meant that necessary interventions and goals to address the resident's skin condition were not documented, potentially impacting the resident's care. The deficiency was identified during an observation of the resident's wound care treatment, where it was noted that the care plan lacked details about the growth's initial identification by a physician. Interviews with facility staff revealed that the resident could have been placed on a wound care doctor's list for review, but this was not included in the care plan. The Director of Nursing acknowledged that any condition with a doctor's order should be care planned, but stated that no harm was done to the resident due to the lack of care planning, as wound care was being performed and the growth was scheduled for removal.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Alice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Alice | 0 mi | — | 11 | 0 |
| Meridian Care Of Alice | 2.4 mi | — | 9 | 4 |
| Windsor Nursing And Rehabilitation Center Of San D | 11.9 mi | — | 0 | 0 |
| Lone Star Ranch Rehabilitaion And Healthcare Cente | 21.6 mi | — | 3 | 0 |
| Kingsville Nursing And Rehabilitation Center | 22.3 mi | — | 5 | 0 |
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