J G Alexander Nursing Center

Based on interview, record review, and resident rights and responsibilities guide review, the facility failed to ensure residents' rights to be informed of and have ready access to the most recent State survey results for all 57 residents residing in the facility during three (3) of three (3) days of survey.Findings include:A record review of the document A Matter of Rights: A Guide to Your Rights and Responsibilities as a Resident, undated, revealed .In addition, you have the right.to review the results of the most recent survey of our facility, and any plans to correct deficiencies.Our policies and procedures.1. We will post the results of the most recent inspection of our facility, together with any plan of correction currently in effect. We encourage residents and family members to review these.On 4/29/26 at 1:39 PM, during an interview in the Resident Council meeting, seven (7) residents with Brief Interview for Mental Status (BIMS) scores of thirteen (13) to (15), which indicated they were cognitively intact, were present. All (7) residents reported they were unaware of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) during care for one (1) of two (2) residents reviewed for perineal and catheter care. Resident #7.Findings include:A review of the facility's policy, Enhanced Barrier Precautions (EBP) Policy, revealed, To reduce the transmission of multidrug-resistant organisms (MDROs) in residents of the facility by implementing Enhanced Barrier Precautions in accordance with guidelines from CDC (Center of Disease Control). Enhanced Barrier Precautions will be implemented for residents who.have indwelling medical devices, including . urinary catheters.have wounds or pressure injuries.Staff must wear gown and gloves during high-contact resident care activities. This includes.device care.Signage: Place appropriated to EBP signage on resident closet door or designated area .A record review of the admission Record revealed the facility initially admitted Resident #7 on 7/5/23 and she was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review, the facility failed to label and date food stored in the refrigerator and freezer and failed to dispose of expired food for one (1) of four (4) days of kitchen observations. Findings include: A review of the facility ' s Food Storage Labeling policy, revised on 10/23, revealed: .8.a.i. Identify the food item's use-by date or expiration date . iv. Food in storage units will be surveyed routinely to identify and discard foods that have passed their manufacturer use-by or expiration date . 2. Refrigerator storage weekly On 01/27/25 at 11:14 AM, during an initial tour with the Dietary Manager (DM), the following observations were made: In Refrigerator #1, one (1) package of sliced ham was opened and unlabeled, and a spill of orange juice was observed on the bottom of the refrigerator. In Refrigerator #3, one (1) bag of bacon bits was opened and unlabeled, and (1) package of sliced roast beef with a use-by date of 09/12/24, received on 10/06/24, was opened. Additionally, three (3) unopened packs of sliced roast beef had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and the facility policy review, the facility failed to honor residents' rights and dignity by not honoring requests for a second bed rail as an enabler and by posting signs at the head of the bed related to resident care for three (3) of 16 sampled residents: Resident #5, Resident #39, and Resident #54. Findings include: A review of the facility's Resident Rights Policy revised in 09/2022 revealed, . Facility will ensure the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of their quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of each resident . Resident #5 On 01/28/25 at 10:51 AM, Resident #5 requested to speak with the State…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review and facility policy review the facility failed to maintain a record log of bed rail maintenance for two (2) of 16 sampled residents (Resident #5 and Resident #54). Findings Include: A record review of the facility's policy, Side Rail Policy, dated 06/25/18, revealed, It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a side or bed rail is used, the facility will ensure correct installation, use, and maintenance of bed rails . Follow the manufacturer's recommendations and specifications for installing and maintaining rails . A record review of the Zenith Series manual revealed . Recommended Maintenance . Regular maintenance of the Long Term Bed is necessary to ensure continuing proper and safe operations . Inspect all fasteners for wear or looseness every six (6) months . On 01/28/25 at 10:51 AM, during an interview and observation, Resident #5 requested to see the State Agency (SA). The resident explained she only had one bed rail on the right side but had asked for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received received necessary behavioral health services to address psychiatric needs and psychotropic medication management. Specifically, the resident was prescribed Rexulti and Trileptal for behavioral health needs in April 2024 but had not been reassessed by a psychiatric provider for ten (10) months which resulted in Resident #45 exhibiting excessive drowsiness, missing multiple meals, and experiencing a significant weight loss of over (10) percent (%) in six months for one (1) of (16) sampled residents. (Resident #45) Findings included: During an observation and interview on 01/27/2025 at 1:01 PM, Resident #45 was in the dining room being assisted by Certified Nursing Assistant (CNA) #1 with eating. The resident's family member was also present. The resident mostly slept throughout the meal, awakening briefly when the family member prompted him to eat. The family member stated that she was concerned because the resident had lost approximately 20 pounds since…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency. Specifically, the facility was cited for failing to label and date food stored in the refrigerator and freezer during an annual recertification survey on 8/3/23 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of nine (9) deficiencies cited. F812 Findings Include: Record Review of the facility's policy Quality Assessment and Performance Improvement (QAPI) Program revised September 2022, revealed, .The facility will .5. To establish that the facility's Quality Assurance and Assessment (QAA) committee has made a good faith attempt to correct an identified quality deficiency, a facility will do more than just subjectively assert it has made a good faith attempt; rather, the facility's actions, taken as a whole, will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and facility policy review the facility failed to ensure items in the kitchen refrigerator/freezer were dated and labeled and food items were discarded by the expiration date for one (1) of three (3) dietary observations. Findings Include: Review of the facility's policy, Storing: Food and Equipment, undated, revealed, Policy:Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illness .Procedure Label .Ensure all food items are labeled . Label information. Each label must contain the following information: Product name .Use-by date.Date the product was prepared or opened . Observation and interview on 7/31/23 at 11:10 AM, during a brief initial tour of the kitchen with the Food Service Director (FSD) revealed the following: 1. Observation of Kitchen refrigerator #1: During an observation and interview, there was a plastic container of a liquid which the FSD identified as tomato juice. It had a discard date of 7/28/23 and the FSD explained that it should have been discarded. There were two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, record review and facility policy review the facility failed to develop and/or implement the comprehensive care plan related to side effects and behavior monitoring for psychotropic medications and the use of an anticoagulant medication for four (4) of (20) residents care plans reviewed. Resident #19, Resident #33, Resident #35, and Resident #160 Findings Include: Record review of the facility's policy, Develop/Implement Comprehensive Care Plan, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Resident #19 During an observation on 7/31/23 at 1:00 PM, Resident #19 was sitting up in bed with her lunch meal in front of her and was served a whole chicken patty on a bun. Her husband stated that he comes to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary medications by failing to monitor resident behaviors and side effects for psychotropic and anticoagulant medication for three (3) of (11) residents reviewed for medications. Resident #33, Resident #35, and Resident #160 Findings Include: A review of the facility's policy, Use of Psychotropic Drugs, (undated), revealed, Policy: Residents are not to be given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medications .Policy Explanation and Compliance Guidelines .9. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication was securely stored for one (1) of 17 sampled residents. Resident # 10. Findings include: Record review of the facility's policy, Label/Store Drugs and Biologicals, (undated), revealed, .The facility will store all drugs and biologicals in locked compartments .and permit only authorized personnel to have access to keys . During an observation on 7/31/23 at 2:30 PM, a container of Dermoplast first aid spray was observed on the back of the commode in Resident #10's bathroom. During an observation and interview with Licensed Practical Nurse #1 (LPN), on 7/31/23 at 2:32 PM, she verified that the can of Dermoplast spray sitting on the back of the commode in Resident #10's bathroom. She explained that she had not been in the resident's bathroom and was not aware that the Dermoplast spray was there. LPN #1 stated that the item should not be stored in the room because another resident could get into the spray and have a negative reaction to it. She verified that Resident #10 did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff and resident representative interview, record review and facility policy review, the facility failed to ensure a mechanical soft, chopped meat diet was provided for one (1) of five (5) residents observed for dining. Resident #19 Findings Include: Review of the facility's policy, Dental Soft Diet (Mechanical), undated, revealed, . Principle:To use regular foods of a consistency which may be easily chewed and swallowed .Food Groups .Meat, Fish, Fowl .Foods Excluded .Any whole meat . On 7/31/23 at 1:00 PM, during an observation and interview, Resident #19 was sitting up in bed with her lunch meal in front of her on an overbed table. She had a whole chicken patty on a bun on her meal tray and her husband stated that he comes to the facility and assists with feeding her lunch. He explained that Resident #19 had eaten some French fries and a little of the Sherbert but could not eat the chicken patty. He explained that it was in her record that her food was supposed to be chopped. In an interview on 08/01/23 at 01:55 PM, with Certified Nurse Aide (CNA) #2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.