Alexandria Care Center

Based on observation, interview, and record review, the facility failed to ensure residents prescribed antipsychotic medications received appropriate Gradual Dose Reductions (GDR) attempts and had indication for continued use when GDRs were attempted and were deemed unsuccessful without clinical justification for 2 of 5 residents reviewed for unnecessary medications (Residents 8 and 12).Findings include:1. During an observation, on 8/11/25 at 11:21 a.m., Resident 8 ambulated up behind another resident and spoke with the other resident. During an observation, on 8/11/25 at 3:04 p.m., Resident 8 sat in a chair in the dining/activity area and participated in an activity. During an observation, on 8/12/25 at 10:06 a.m., Resident 8 ambulated around the tables in the dining area and observed the Activity Director setting up a bucket activity. During an observation, on 8/12/25 at 3:49 p.m., Resident 8 stood at the dining table and worked on a puzzle. During an observation, on 8/13/25 at 8:22 a.m., Resident 8 ambulated down the hall to the dining room. During an observation, on 8/14/25 at…

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 record review and interview, the facility failed to ensure the resident's representative was notified in writing of transfer/discharge appeal rights and the facility bed hold policy for 4 of 7 residents reviewed for hospitalizations (Resident 6, 7, 22, and 57) and failed to provide communication to the receiving health care facility for 1 of 7 residents reviewed for hospitalizations. (Resident 22)Findings include: 1.Resident 7's clinical record was reviewed on 8/14/25 at 9:04 a.m. Diagnoses included Alzheimer's disease, vascular dementia, unspecified severity, with agitation, dementia, moderate, with agitation, unspecified dementia, unspecified severity, with other behavior disturbance, and major depressive disorder, recurrent, severe with psychotic symptoms. A nursing progress note, dated 6/3/25 at 7:22 p.m., indicated the resident became physically aggressive and threw clothing items, hangers, and a television out of the resident's room. She tried to slam her walker into the staff members. A referral…

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 and interview, the facility failed to administer a PRN (as needed) medication per physician orders for 2 of 16 residents reviewed for physician orders. (Resident 35 and Resident 5)1.Resident 35's clinical record was reviewed on 8/13/25 at 1:56 p.m. Diagnoses included Alzheimer's disease, essential hypertension (high blood pressure), and atrial fibrillation (irregular heartbeat).Current orders included hydralazine 10 milligrams four times a day as needed for high blood pressure [to lower blood pressure]. Special instructions included: administer the medication when Resident 35's blood pressure was above 165 [systolic (top number)].The clinical record indicated the following:On 7/1/25 the resident's blood pressure was 170/83. Hydralazine was not administered.On 7/6/25 the resident's blood pressure was 198/87. Hydralazine was not administered.On 7/14/25 the resident's blood pressure was 181/77. Hydralazine was not administered.On 7/15/25 the resident's blood pressure was 169/73. Hydralazine was not administered.On 7/17/25 the resident's blood pressure was 170/72.…

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, and record review, the facility failed to follow the dietitian's recommendations and follow a physician's order for a resident with significant weight loss for 1 of 3 residents reviewed for nutrition. (Resident 8) Finding includes:During an observation, on 8/13/25 at 7:48 a.m., Resident 8 was eating her biscuits and gravy. She had white milk on her tray. Resident 8's clinical record was reviewed on 8/13/25 at 8:49 a.m. Diagnoses included Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, mild, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition, Vitamin D deficiency, vomiting, and underweight. Current orders included the following: regular diet, chocolate milk with meals, cottage cheese with meals, vanilla ice cream with lunch and dinner, yogurt with breakfast, Boost (supplement) high protein - give 350 ml (milliliters) three times a day, Boost…

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 and interview, the facility failed to ensure medications were stored in a secure manner when one medication cart was left unlocked and unattended. This deficiency had the potential to allow access to medications belonging to 19 residents. Findings include:During an observation on 8/12/25 at 11:03 a.m., the 100-hallway medication cart was unattended and unlocked. The hallway was empty until 11:10 a.m. when two (unidentified) Certified Nursing Assistants (CNAs) approached and entered a nearby resident room. At approximately 11:15 a.m., LPN 5 approached and locked the medication cart. She indicated she was the nurse responsible for the medication cart. She had inadvertently left the cart unlocked. Keys to the cart were in her pocket. The cart contained medications for 19 residents.During an interview with the Director of Nursing (DON) on 8/15/25 at 3:53 p.m., she indicated all medication carts should be locked when not in use.A current facility document, titled Storing Drugs, provided by the DON on 8/15/25 at 3:02 p.m., indicated the following: .Drugs and…

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 and interview, the facility failed to ensure hygienic food handling practices were followed during dining services for 1 of 19 residents observed in the main dining room. (Resident 35)Findings include:During an observation, on 8/11/2025 at 12:06 p.m., CNA 4 offered to cut Resident 35's hamburger sandwich. Using her left hand, CNA 4 placed all five of her fingertips on the top bun and pushed the top bun in a downward motion to secure the bun in place as she used a knife, in her right hand, to cut the sandwich in half. During an interview, on 8/11/2025 at 12:43 p.m., CNA 4 indicated she should not have touched Resident 35's food with her bare hands. Food was not to be touched barehanded and a fork and knife was to be used to cut a sandwich. During an interview, on 8/15/25 at 3:39 p.m., the DON indicated staff were not to touch resident's food with bare hands. All staff were previously educated on hand hygiene, food handling, and other specifics of food service(s). A facility policy, dated August 2024, provided by the DON on 8/15/25 at 3:02 p.m., titled Glove Use &…

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 interview and record review, the facility failed to prevent a significant medication error, resulting in the hospitalization of a resident for altered mental status. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 7/2/25 at 11:08 a.m. Diagnoses included displaced fracture of right femur, atrial fibrillation (irregular heartbeat), heart disease. The resident admitted to the facility from the hospital on 6/27/25. Current physician orders include buprenorphine-naloxone (treats narcotic dependence) 8-2 milligram (mg) sublingual twice a day, tramadol (opiate pain medication) 50 mg every six hours, ciprofloxacin (antibiotic) 500 mg one tablet twice a day for three days for urinary tract infection (UTI), iron 325 mg one tablet daily for anemia, and potassium gluconate 595 mg daily for hypokalemia. A current care plan, dated 6/27/25, indicated Resident B was at risk for atrial fibrillation. Interventions included administering medication as ordered, aspirin as ordered, Eliquis as ordered, monitor vital signs as needed, notify physician if any…

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 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. A Consultant Pharmacist's Medication Regimen Review for May 2024, provided by the DON on 8/28/24 at 2:09 p.m., indicated the Medication Administration Report (MAR) showed that in the last couple of weeks, this dose was administered eight times when the residents systolic blood pressure was less than 120. Please make sure to hold when indicated. A Medication Administration Report (MAR), for June 2024, indicated the resident received metoprolol…

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, and record review, the facility failed to provide a dignified dining experience for 1 of 14 residents observed during dining on the secured unit. (Resident 35) Finding includes: During an observation, on 8/26/24 at 12:32 p.m., Resident 35 sat in her wheelchair at the dining table. Her chair was low in comparison to the table height and put the resident at chin level to the table. She took a bowl of food off her tray on the table and put the bowl in her lap to eat. During an observation, on 8/27/24 at 12:17 p.m., CNA 6 assisted the resident in her wheelchair to the dining table. The resident's chin was at the level of the table and close to the table edge. She reached up to the tray on the table to get some potato chips. During an observation, on 8/28/24 at 12:14 p.m., the resident sat at the dining table. Her chin was at table height. She reached up to get a food bowl from her tray and held it while eating. Resident 35's clinical record was reviewed on 8/26/24 at 3:54 p.m. Her diagnoses included Alzheimer's disease with late onset, dementia, visual…

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 and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis. (Resident 12) Finding includes: Resident 12's clinical record was reviewed on 8/27/24 at 1:49 p.m. Diagnoses included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (1/20/23), schizophrenia (1/20/23), major depressive disorder (1/20/23), generalized anxiety disorder (4/28/23), psychotic disorder with delusions due to known physiological condition (5/31/23), and restlessness and agitation (5/31/23). Physician's orders included buspirone (antianxiety) 10 mg twice a day (started 8/13/24), lamotrigine (for schizophrenia) 25 mg twice a day (started 8/18/23), and olanzapine (antipsychotic) 15 mg twice a day (started 8/13/24). A care plan for physical behavior symptoms directed towards others, initiated on 5/11/23 and last revised on 8/8/24, indicated the resident exhibited physical behavioral symptoms directed towards others…

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, record review, and interview, the facility failed to develop and implement individualized interventions to reduce physical aggression toward a resident (Resident 29) by a resident with dementia (Resident 23). Findings include: During an observation, on 9/29/23 at 8:50 a.m., Resident 23 was sitting in a wheelchair in the lounge with six other residents. Her clinical record was reviewed on 9/29/23 at 2:06 p.m. Diagnoses included, dementia, unspecified severity, with agitation, anxiety, depression, and psychotic disorder with delusions due to known physiological condition. Current physician orders included Rexulti (anti-psychotic), 1 mg (milligram) tablet once a day, with an order date of 6/21/23, Remeron (antidepressant), 15 mg tablet once a day at bedtime, with an order date of 8/22/23, and Zoloft (antidepressant), 100 mg tablet, take one and one-half tablets to equal 150 mg once a day, with an order date of 8/22/23. A 7/15/23 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. She required supervision with bed mobility and…

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, record review, and interview, the facility failed to ensure medication was secured after medication administration for 1 of 4 residents observed during medication administration (Resident 11). Finding includes: During an observation, on 10/3/23 at 9:55 a.m., Resident 11 was given his medications crushed in pudding, followed by sips of nectar thick liquid containing polyethylene glycol (laxative). The resident became fatigued while swallowing his medications and LPN 51 placed the cup of the remaining liquid containing the polyethylene glycol on the resident's bedside table, left the room, and pushed the medication cart down the hallway. During an interview, at the time of the observation, LPN 51 indicated she was leaving the cup containing the liquid and polyethylene glycol for the CNAs (certified nurse aides) to help the resident to drink later. During an interview, on 10/3/23 at 1:50 p.m., the DON indicated LPN 51 should have taken the cup of liquid with medication with her when she left the room. A current facility policy, revised 4/2017, titled Medication…

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 record review and interview, the facility failed to ensure 1 of 7 residents reviewed for immunizations received a pneumococcal vaccination to remain up to date with pneumococcal vaccination (Resident 24). Finding includes: Resident 24's clinical record was reviewed on 9/29/23 at 3:40 p.m. His diagnoses included chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease of the coronary artery, and chronic kidney disease. An Informed Consent for Pneumococcal Vaccine form was signed by the resident's legal representative on 1/25/22. An Immunization/Mantoux Record, provided by the Administrator on 10/2/23 at 3:44 p.m., indicated the resident had received the pneumococcal 13-valent conjugate vaccine on 3/25/22. The form lacked documentation of a refusal or a medical contraindication for an additional pneumococcal vaccination. During an interview, on 10/2/23 at 4:08 p.m., the Administrator indicated the immunization records had been removed from the paper charts. Medical records staff had…

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.