J G Alexander Nursing Center

F-F758

Findings included:

During an observation and interview on 01/27/2025 at 1:01 PM, with Resident #45's family member, the resident was in his room for lunch. He was drowsy and did not wake up for the CNA who was attempting to feed him. He eventually woke up to eat two (2) small bites of food when encouraged by the family member.

The family member expressed concern that the resident had lost approximately 20 pounds since being discharged from a behavioral health hospital in March 2024.

During an observation on 01/28/2025 at 12:10 PM, Resident #45 was in the dining hall but remained asleep throughout the entire lunch period and did not wake up despite multiple attempts by CNA #1.

During an interview on 01/29/2025 at 11:23 AM, Registered Nurse (RN)#2 stated that psychiatric services were being ordered for Resident #45 because his son requested a psychiatric consultation on 01/24/2025. RN #2 confirmed that the resident had not received a psychiatric follow-up since returning from the behavioral health hospital ten (10) months ago.

During an observation on 01/29/2025 at 1:59 PM, Resident #45 was asleep in his wheelchair in the common area near the nurses' station.

During an interview on 01/29/2025 at 3:12 PM, the Director of Nursing (DON) confirmed that a psychiatric consultation for medication management had not been in progress until the resident's son requested the consultation on 01/24/2025. The DON stated that it was standard practice for the facility's Medical Doctor of Behavioral Health (MDB) to follow up with residents discharged from behavioral health units but acknowledged that this did not occur in this case.

During an observation on 01/30/2025 at 9:35 AM, Resident #45 was asleep in his wheelchair in his room.

On 01/30/2025 at 11:45 AM, during an interview the Medical Director stated he was unaware of the resident's weight loss and had not been notified by nursing staff. He stated that the resident was prescribed multiple psychotropic medications, including Rexulti, which could cause lethargy, and Trileptal, which could affect appetite. He explained that he should have been informed of the weight loss through dietitian reports in Quality Assurance meetings but had not been made aware. He acknowledged that the weight loss should have been addressed sooner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0692 During an interview on 01/30/2025 at 1:41 PM, RN #3 stated that Resident #45 had exhibited altered sleep patterns prior to his psychiatric hospitalization but that his drowsiness had worsened in the past few months, Level of Harm - Actual harm causing him to miss meals.

Residents Affected - Few A record review of the Progress Notes revealed Resident #45 had a Nutrition/Dietary Note, 9/11/2024, authored by the Registered Dietitian (RD), that indicated, .WT (Weight) Change: -3.7% x (times) 1 mo (month), -6.6% WL (Weight Loss) x 3 mo, -18.8% SWL (Significant Weight Loss) x 6 mo .Comments .Intake does not meet nutritional needs. Resident has experienced a continued WL with a SWL for 6 mo. Resident observed asleep in bed this morning. Resident has been receiving a SF (Sugar Free) house supplement TID (three times daily) but this was DC'd (Discontinued) on 9/10/25. Oral intake of meals has declined over the last month .Interventions: 1. House Supplement 8 oz (ounces) TID at medpass - document intake on eMAR (electronic Medication Administration Record) .

A record review of the Progress Notes revealed Resident #45 had a Nutrition/Dietary Note, 11/13/2024, authored by the Registered Dietitian (RD), that indicated, .Resident has experienced SWL x 6 mo. RD recommended a house supplement 8 oz BID at medpass at last visit in October. It does not appear the supplement was implemented .WT Change .-13% SWL x 6 mo .Comments .Intake does not meet nutritional needs .RD recommended a supplement at the last 2 visits. Recommendation was not implemented . Interventions: 1. House Supplement 8 oz BID at medpass - document intake on eMAR .

A record review of Resident #45's weight summary revealed that the resident weighed 191 pounds on 03/04/2024 and 158 pounds on 01/17/2025, reflecting a total weight loss of 33 pounds in ten (10) months.

A record review of Resident #45's meal intake percentages from 01/01/2025 through 01/28/2025 revealed his documented meal intake was between 0-25 percent of meals on thirteen (13) of twenty-eight (28) days.

A record review of the eMAR for Resident #45 for October 2024, November 2024, December 2024, and January 2025 revealed there was no documentation that MedPass was administered as recommended by

the RD.

A record review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed in Section N that the resident received antipsychotics on a routine basis. Section K revealed the resident had lost five (5) % percent or more of his weight in the last month or ten (10) % in the last six months. Section I indicated that the resident had current diagnoses of Alzheimer's Disease and Dementia. Section C revealed a Brief Interview for Mental Status (BIMS) score of (5), which indicated the resident's cognition was severely impaired.

A record review of the Order Summary Report with active orders as of 1/29/25 revealed Resident #45 had a physician's order dated 3/4/24 for a Low concentrated sweets diet with regular texture related to Type 2 Diabetes Mellitus with hyperglycemia, an order dated 4/2/24 for Trileptal 150 milligrams (mg) to be given twice daily for Dementia with Agitation and Depression and an order dated 4/2/24 for Rexulti 1 mg to be given daily for Dementia with Agitation. There were no current orders for the House Supplement of MedPass as recommended by the RD.

A record review of Resident #45's Admission Record revealed the facility admitted the resident on 03/04/2024 with a diagnosis of Alzheimer's Disease, with an onset date of 04/04/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 43283 Residents Affected - Few 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 another on

the left. She was told the state removed the bed rails. She stated she had at least six (6) falls from rolling out of bed and expressed a desire for another bed rail to assist with turning and to feel safer at night. She recently elected to undergo a hip replacement and stated she needed both rails to assist with turning in bed.

The SA observed a half-bed rail on the right side of the bed. The resident explained that she had a recliner

on the left side, which she used to assist with turning if she could reach it. However, she stated that this method was unsafe and that she was afraid of rolling out of bed. She also reported shaking the bed rail daily to ensure it was not too loose. The bed rail was observed to be loose but intact.

On 01/28/25 at 3:00 PM, during an interview and observation, Resident #54 explained that he had been at

the facility for almost a year. He stated that, while on therapy load, he asked why he could not have another bedrail on the left side of his bed to assist with turning and repositioning. The resident denied any upper arm weakness and stated he had asked staff for another bed rail but was told he could only have one. He clarified that he did not want or need four (4) bed rails but would like a second to assist with turning.

On 01/29/25 at 2:20 PM, during an interview, Maintenance #1 explained that upon admission, if a resident needed a bed rail, the therapy director or nursing department notified him to install one. He stated that this was usually done upon admission and that he did not perform any maintenance on the bed rail or bed afterward unless staff submitted a complaint in the maintenance logbook at the nurse's station. He stated he had never checked bed rails for security or looseness unless staff reported an issue and submitted a maintenance request work order. He further stated that he did not maintain a log for bed rail maintenance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0700 On 01/27/25 at 1:41 PM, during an observation, Resident #54 was observed upright in bed with one (1) bed rail up. The resident questioned why he did not have all four (4) rails up as he did in the hospital. He stated Level of Harm - Minimal harm or that he had requested another bed rail to help with positioning but was told he could only have one. potential for actual harm

On 01/29/25 at 2:45 PM, during an interview, the Administrator stated that he was not aware of any log for Residents Affected - Few bed or bed rail maintenance. He confirmed that the facility had a maintenance book at the nurse's station and that staff were expected to document maintenance needs in the book.

On 01/30/25 at 11:00 AM, during an interview, the Maintenance Director stated that he could not find any maintenance guidelines related to bed rails. He explained that he installed the bed rails by sliding the pins into the slots and did not check them again unless a maintenance request was submitted.

On 01/30/25 at 2:30 PM, during an interview, the Administrator reported that he was not aware that maintaining a log of bed rail maintenance was a requirement but stated that the facility would make changes to comply with regulations.

A record review of Resident #5's Admission Record revealed the facility admitted her initially on 12/05/22 with diagnoses of Other Chronic Pain and Presence of Neurostimulator.

A record review of Resident #5's Bedrails Consent revealed that her daughter signed the consent on 08/01/24. The consent did not specify the use of only one bed rail. The question Do you choose to use bedrails on your bed while in the facility? was checked Yes.

A record review of Resident #54's Admission Record revealed the facility admitted him on 02/21/24 with diagnoses of Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region and Rheumatoid Arthritis, Unspecified.

A record review of Resident #54's Bedrails Consent dated 02/21/24 revealed an X in place of a signature.

The consent did not specify the use of only one bed rail. The question Do you choose to use bedrails on your bed while in the facility? was checked Yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 43283 minimal harm Based on observations, interviews, and facility policy review the facility failed to post daily nursing staffing Residents Affected - Some information in a clean and readable format in a prominent place readily accessible to residents and visitors.

The postings also failed to include the facility name, date, census, and the total number and actual hours worked per shift for two (2) of four (4) survey days.

Findings include:

A record review of the facility's policy, Posted Nurse Staffing Information, revised in September 2022, revealed: . The facility posts the following information on a daily basis: 1. Facility Name 2. Current date 3.

The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: . 4. Resident census. The facility must post the nurse staffing data mentioned above on a daily basis at the beginning of each shift. The data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors .

On 01/27/25 at 3:00 PM, during a walk-through of the facility, the State Agency (SA) observed no staffing posting.

On 01/28/25 at 9:25 AM, during a walk-through of the facility, no staffing posting was observed.

On 01/28/25 at 10:25 AM, during an interview, the Director of Nursing (DON) explained that staffing is usually posted around the nurse's station and that there is also a binder containing staffing information.

On 01/28/25 at 3:25 PM, during a walk-through of the facility, no staffing posting was noted.

On 01/29/25 at 1:50 PM, during an interview, Registered Nurse (RN) #1 stated that staffing had never been posted since she had been at the facility. She explained that she fills out the staffing information daily and that it is kept in a binder. She also reported that she completed the total number of hours most days at the end of her shift.

On 01/29/25 at 2:00 PM, during an interview, the DON and Administrator both stated that they were not aware staffing had to be visibly posted daily. They understood that staffing information had to be available for access if someone requested to view it, but not that it needed to be visibly displayed. They stated that this issue would be addressed, and that staffing would be posted daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm 50751

Residents Affected - Few 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 being discharged from a behavioral health hospital in March 2024. She explained the resident had been increasingly drowsy and sleeping throughout the day.

During an observation on 01/28/2025 at 12:10 PM, Resident #45 was in the dining hall but remained asleep throughout the entire lunch period and did not wake up despite multiple attempts by CNA #1.

During an interview on 01/29/2025 at 11:23 AM, Registered Nurse (RN) #2 stated that psychiatric services were being ordered for Resident #45 because his son requested a psychiatric consultation on 01/24/2025. RN #2 confirmed that the resident had not received a psychiatric follow-up since returning from the behavioral health hospital ten (10) months ago.

During an observation on 01/29/2025 at 1:59 PM, Resident #45 was asleep in his wheelchair in the common area near the nurses' station.

During an interview on 01/29/2025 at 3:12 PM, the Director of Nursing (DON) confirmed that a psychiatric consultation for medication management had not been in progress until the resident's son requested the consultation on 01/24/2025. The DON stated that it was standard practice for the facility's Medical Doctor of Behavioral Health to follow up with residents discharged from behavioral health units but acknowledged that

this did not occur in this case.

During an observation on 01/30/2025 at 9:35 AM, Resident #45 was asleep in his wheelchair in his room.

On 01/30/2025 at 11:45 AM, during an interview, the Medical Director stated that typically, the facility's psychiatric Nurse Practitioner evaluates residents returning from psychiatric hospitalization s. He confirmed that Resident #45 should not have gone (10) months without a psychiatric follow-up and stated that a psychiatric consultation should have been completed within 90 days of admission to a behavioral health unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0740 On 01/30/2025 at 1:41 PM, during an interview, RN #3 stated that Resident #45 had exhibited altered sleep patterns prior to his psychiatric hospitalization but that his drowsiness had worsened in the past few months, Level of Harm - Minimal harm or causing him to miss meals. potential for actual harm

A record review of Resident #45's Admission Record revealed the facility admitted the resident on Residents Affected - Few 03/04/2024 with a diagnosis of Alzheimer's Disease, with an onset date of 04/04/2024.

A record review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed that the resident was currently prescribed an antipsychotic medication. The MDS also revealed the resident had lost five (5) percent or more of his weight in the last month or ten (10) % in the last six months. Section I indicated the resident had current diagnoses of Alzheimer's Disease and Dementia. Section C revealed a Brief Interview for Mental Status (BIMS) score of (5), which indicated the resident's cognition was severely impaired.

A record review of the Order Summary Report with active orders as of 1/29/25 revealed Resident #45 had a physician's order dated 3/4/24 for a Low concentrated sweets diet with regular texture related to Type 2 Diabetes Mellitus with hyperglycemia, an order dated 4/2/24 for Trileptal 150 milligrams (mg) to be given twice daily for Dementia with Agitation and Depression and an order dated 4/2/24 for Rexulti 1 mg to be given daily for Dementia with Agitation.

A record review of the facility's psychiatric consultation/referral criteria revealed that symptoms warranting a psychiatric consultation/referral included being prescribed an antipsychotic medication and experiencing changes in mood, withdrawing,or apathy (marked indifference to environment).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50921

Residents Affected - Many 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 ,d+[DATE REDACTED], 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 [DATE REDACTED] 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 [DATE REDACTED], received on [DATE REDACTED], was opened. Additionally, three (3) unopened packs of sliced roast beef had a use-by or freeze-by date of [DATE REDACTED]. A five (5)-lb bag of shredded cheddar cheese was opened and unlabeled. Also, a thawed, unopened fire-braised pork loin with a use-by or freeze-by date of [DATE REDACTED], received on [DATE REDACTED], was observed. The DM confirmed these items were expired and collected them for disposal. In Freezer #1, one (1) bag of frozen biscuits was open and unlabeled. In Freezer #2, one (1) bag of frozen chicken patties and (1) package of hamburger patties was open and unlabeled. A 10-inch pecan pie with an expiration date of [DATE REDACTED] was also observed. In the dry storage room, (1) 48-oz container of Real Lemon Juice was observed opened on [DATE REDACTED] but not stored in the refrigerator, despite manufacturer instructions to refrigerate after opening.

On [DATE REDACTED] at 11:20 AM, the DM confirmed the presence of expired and improperly stored food items and collected them for disposal.

On [DATE REDACTED] at 11:10 AM, during an interview, the Certified Dietary Manager (CDM) and Registered Dietitian (RD) stated that their expectations for kitchen staff include completing education and training for their positions, following federal guidelines, and adhering to food labeling and handling policies to prevent foodborne illness among residents.

On [DATE REDACTED] at 02:00 PM, during an interview, the Administrator revealed that he was aware that some items had been out of date but had since been discarded. He explained that the facility added a kitchen in [DATE REDACTED] because the previous contract with the local hospital's kitchen to service residents ended in [DATE REDACTED]. The Administrator stated there is now a completely different kitchen staff and that he believes the staff is competent. He also noted that the facility changed food providers in [DATE REDACTED], which may have contributed to expired foods being delivered to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43283 potential for actual harm Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Residents Affected - Few 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 [DATE REDACTED] 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.

F-F812, .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 .

During the current annual recertification survey, the facility failed to label and date food stored and dispose of expired foods in the refrigerator and freezer in one (1) of four (4) days in kitchen observations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 255318 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 255318 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

J G Alexander Nursing Center 25112 Highway 15 Union, MS 39365

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 0865 On [DATE REDACTED] at 12:20 PM, during an interview, Registered Nurse (RN) # 3 who was previously responsible for QAPI stated that she was still overseeing QAPI despite the facility hiring someone else for the role. She Level of Harm - Minimal harm or explained that the new hire had not yet taken over the responsibilities, and the facility had scheduled a potential for actual harm meeting to address the transition. RN #3 stated she was unaware that food storage issues were still occurring in the kitchen. She explained that at the time of the last survey, the facility's kitchen was associated Residents Affected - Few with the hospital, but since [DATE REDACTED], the facility had transitioned to its own independent kitchen. Since that transition, the kitchen staff has undergone several turnovers, and the facility was now on its third kitchen director. RN #3 reported that after the last survey on [DATE REDACTED], concerns related to food storage were discussed in QAPI meetings every month for the first four (4) months. She stated that audits were completed and submitted to the Director of Nursing (DON) until [DATE REDACTED]. However, she acknowledged that no further kitchen audits had been conducted since then, nor had kitchen issues been discussed, as the facility believed the concerns had been addressed with the new kitchen. She confirmed that although the facility had implemented the initial plan of correction, it failed to sustain those corrective actions following kitchen staff turnover and operational changes. RN #3 stated she would present these concerns to the QAPI committee again to develop new action plans and resume audits of the kitchen.

On [DATE REDACTED] at 2:30 PM, during an interview, the Administrator and the DON confirmed that the facility had completed the plan of correction for the previous kitchen-related deficiency from [DATE REDACTED]. The Administrator stated that the kitchen had been in operation since [DATE REDACTED] and had undergone multiple staff turnovers. He further stated that he had spoken with the new kitchen manager, who was currently in training, and that they planned to continue addressing the kitchen-related concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 255318