Resident #45 weighed 191 pounds when he entered J G Alexander Nursing Center in March 2024. By January 2025, he weighed 158 pounds.
His family member told inspectors on January 27 that the resident had lost approximately 20 pounds since his discharge from a behavioral health hospital in March 2024. During the lunch visit, the resident was drowsy and didn't wake up for the nursing assistant trying to feed him. He eventually woke to eat two small bites when encouraged by his family member.
The next day, inspectors watched Resident #45 remain asleep throughout the entire lunch period in the dining hall. The nursing assistant made multiple attempts to wake him but failed.
On January 29, inspectors found him asleep in his wheelchair in the common area near the nurses' station at 1:59 PM.
The following morning, he was asleep in his wheelchair in his room at 9:35 AM.
Registered Nurse #3 told inspectors on January 30 that the resident had exhibited altered sleep patterns before his psychiatric hospitalization, but his drowsiness had worsened in recent months, causing him to miss meals.
The facility's medical director was unaware of the weight loss when inspectors interviewed him on January 30. He said nursing staff had never notified him, though he should have been informed through dietitian reports in quality assurance meetings. He acknowledged the weight loss should have been addressed sooner.
The resident was prescribed Rexulti and Trileptal for dementia with agitation and depression. The medical director explained that Rexulti could cause lethargy and Trileptal could affect appetite.
Records showed the resident had not received psychiatric follow-up for 10 months since returning from the behavioral health hospital.
Registered Nurse #2 confirmed on January 29 that psychiatric services were being ordered only because the resident's son requested a consultation on January 24. The Director of Nursing acknowledged this was standard practice after behavioral health discharge but admitted it didn't occur in this case.
The medical director told inspectors that typically the facility's psychiatric nurse practitioner evaluates residents returning from psychiatric hospitalization. He confirmed Resident #45 should not have gone 10 months without psychiatric follow-up and stated consultation should have been completed within 90 days of behavioral health admission.
The registered dietitian documented significant concerns twice in fall 2024. A September 11 note indicated the resident had experienced 18.8% weight loss over six months, with intake not meeting nutritional needs. The dietitian observed the resident asleep in bed that morning and noted his oral intake had declined over the previous month.
The dietitian recommended house supplements three times daily, but records showed these were never implemented.
An November 13 dietitian note revealed the resident had experienced significant weight loss over six months, with 13% weight loss documented. The note stated: "RD recommended a supplement at the last 2 visits. Recommendation was not implemented."
Records of the resident's meal intake from January 1 through January 28, 2025 showed he consumed between 0-25% of meals on 13 of 28 days.
The facility's medication administration records for October, November, and December 2024, and January 2025 contained no documentation that the recommended supplements were ever given.
The resident's November 27 assessment indicated he was receiving antipsychotics routinely and had lost 5% of his weight in the previous month or 10% in six months. The assessment showed severe cognitive impairment with a score of 5 on the mental status exam.
Active physician orders as of January 29 included the psychiatric medications but no orders for the house supplements recommended by the dietitian.
Beyond the weight loss case, inspectors found the facility failed to maintain bed rail safety logs and never posted required daily nursing staffing information.
Resident #5 told inspectors she had requested a second bed rail after at least six falls from rolling out of bed. She was scheduled for hip replacement surgery and needed both rails to assist with turning. She reported shaking her bed rail daily to ensure it wasn't loose. Inspectors observed the rail was loose but intact.
Resident #54 explained he had asked for a second bed rail to assist with turning and repositioning but was told he could only have one.
Maintenance staff told inspectors they installed bed rails upon admission but performed no routine maintenance unless staff submitted complaints. The maintenance director said he could not find any guidelines for bed rail maintenance and didn't check rails again after installation unless a work order was submitted.
The facility's policy required following manufacturer recommendations for bed rail maintenance. The bed manual specified inspecting all fasteners for wear or looseness every six months, but no maintenance logs existed.
Inspectors found no daily nursing staffing information posted anywhere in the facility during the four-day survey. The Director of Nursing and Administrator told inspectors they were unaware staffing had to be visibly posted daily, believing it only needed to be available if someone requested to view it.
In the kitchen, inspectors found expired and improperly labeled food throughout refrigerators and freezers. Opened packages of sliced ham, bacon bits, and shredded cheese were unlabeled. Multiple packages of sliced roast beef and a pork loin were past their use-by dates. A container of lemon juice was stored at room temperature despite requiring refrigeration after opening.
The facility had been cited for identical food labeling and storage violations during a previous survey, indicating the quality assurance program failed to prevent recurrence.
The Administrator explained the facility had changed both kitchen staff and food providers recently after ending a contract with a local hospital's kitchen service.
Resident #45's family member watched him struggle to stay awake long enough to take two bites of food, unaware that dietary recommendations to address his dramatic weight loss had been ignored for months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for J G Alexander Nursing Center from 2025-01-30 including all violations, facility responses, and corrective action plans.