Alexandria Care Center

In the surveyor’s words

From the most serious findings on record at Alexandria Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 18, 2021

  Based on interview and record review, the facility failed to ensure adequate supervision to prevent fall and injuries for one of three sampled residents, (Resident 1), who was assessed as at risk of elopement (a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave), had wandering behavior (aimless, slow, or pointless movements, meandering, or repetitive locomotion that exposes the individual to harm; it is frequently incongruent with boundaries, limits, or/and obstacles). […]

• Actual harm, isolatedF840Nov 18, 2021

  Based on interview and record review, the facility failed to follow contract agreements between the facility and Transportation Company 1 (TC 1) and the facility and [CONDITION(S)] Center (DC - an outside treatment center, for residents who require [CONDITION(S)]- a procedure for removal of accumulated waste from the blood) to ensure the safety of one of three sampled residents (Resident 1). On 9/4/2021 at 12:20 p.m., TC 1's driver (Driver 1) picked up Resident 1, who was confused, at risk of elopement (a patient who leaves a health facility when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave), to transport him to DC. […]

• No harm, potential for more than minimal, widespreadF814May 22, 2026

  Based on observation, interview, and record review, the facility failed to properly dispose of garbage when: a. The trash can was not completely closed when not in use in the kitchen. b. The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) contained dried brown residue on its exterior and the surrounding floors had visible trash and debris. These failures had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 164 of 164 facility residents. Findings: a. […]

• No harm, potential for more than minimal, patternF604May 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 15, 155,10, and 147) reviewed for physical restraints by failing to ensure: 1. Resident 15 did not have bilateral (both right and left side) foam wedge cushions (firm, triangular-shaped foam cushion used to elevate parts of the body) tucked under the fitted sheet while the resident lay in bed. 2. […]

• No harm, potential for more than minimal, patternF658May 22, 2026

  Based on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care to two of five sampled residents (Residents 13 and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. […]