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, isolatedF689Apr 28, 2026

  Based on observation, interview, and record review, the facility failed to provide supervision to mitigate the risk of repeated falls and failed to ensure individualized fall interventions were developed, added to the plan of care, and implemented to prevent repeated falls for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in the resident suffering a left hip fracture requiring surgical repair. Finding includes: Resident B' s clinical record was reviewed on 4/27/26 at 11:41 a.m. Diagnoses included Alzheimer's disease, displaced intertrochanteric fracture of the left femur, insomnia, trigeminal neuralgia, and anxiety. […]

• Actual harm, isolatedF689Sep 23, 2021

  Based on observation, record review and interview, the facility failed to provide adequate supervision and appropriate interventions to prevent falls for residents with a history of falls for 2 of 3 residents reviewed for falls (Residents B and D). This deficient practice resulted in Resident B sustaining a fracture of the fibular neck. Findings include: 1. On 9/22/21 at 1:42 p.m. Resident B was observed sitting in her wheelchair in her room watching television. On 9/23/21 at 1:40 p.m. a staff member from the therapy department was talking to her while she sat in her wheelchair in her room. Resident B's clinical record was reviewed on 9/22/21 at 9:46 a.m. […]

• No harm, potential for more than minimal, patternF684Aug 30, 2024

  Based on interview and record review, the facility failed to monitor vital signs per physician orders prior to giving medications for 3 of 3 residents reviewed. (Resident 24, 31, and 35) Findings include: 1. Resident 24's clinical record was reviewed on 8/27/24 at 9:45 a.m. Diagnoses included dementia, old myocardial infarction (heart attack), unspecified atrial fibrillation (rapid and irregular heart rate), and hypertension (high blood pressure). Resident orders included metoprolol tartrate (high blood pressure) 25 milligram (mg) tablet twice daily, hold if heart rate is below 60 and/or systolic blood pressure (top number) is below 120. […]

• No harm, potential for more than minimal, patternF644Aug 12, 2022

  Based on record review and interview, the facility failed to complete Preadmission Screening and Resident Review (PASRR) for residents newly diagnosed with mental illness for 4 of 7 residents reviewed for PASRR (Residents 19, 5, 31, and 33). Findings include: 1. Resident 19's clinical record was reviewed on 8/8/22 at 10:22 a.m. Diagnoses included, but were not limited to, depression, dementia, delusional disorder, [CONDITION(S)] disorder. She had a current, 7/29/21, care plan problem of delusions and hallucinations of things being wet such as her bed, blanket, briefs, or pants and the belief she was dying. Review of a PASRR level 1 assessment, dated 11/10/19, did not indicate mental health diagnoses were present. […]

• No harm, potential for more than minimal, patternF758Sep 3, 2021

  Based on observation, interview and record review, the facility failed to ensure residents who received psychoactive medications had adequate indications for use (targeted behavioral systems), had documented behavioral systems, had care plan regarding behavioral systems, and/or had contraindications for gradual dose reductions which identified targeted behaviors and clinical rationale why any additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior for 4 of 4 residents reviewed for psychoactive medication use (Residents 18, 19, 5 and 29). Findings include: 1. […]