Resident 141 was prescribed Pradaxa, a medication used to prevent blood clots in patients with atrial fibrillation. The facility's own care plan, initiated December 31, 2024, stated the resident was "at risk for injury or complications related to the use of anticoagulation therapy medication Pradaxa" and instructed staff to "observe for active bleeding, i.e. hematuria, bruising, guaiac+ (bloody) stool, nose bleeds, bleeding gums, etc."
But inspectors found no documentation that staff monitored the resident for bleeding between January 1 and January 30, 2025.
The Director of Nursing told inspectors she was "unable to locate documentation for monitoring for bleeding related to the use of Pradaxa for Resident 141" during that period. She acknowledged that monitoring for bleeding was "important to ensure Resident 141 does not have bleeding that was unnoticed, which may harm the resident and require hospitalization."
The oversight was part of broader care planning failures at Alexandria Care Center that federal inspectors documented during their January 31 visit.
Resident 145 used bilateral upper siderails to help with turning and repositioning in bed due to spinal stenosis, nerve damage, lack of coordination, and muscle weakness. The resident told inspectors "the siderails are always up." Yet the facility had no care plan addressing the use of siderails, despite having a policy requiring one.
A registered nurse told inspectors that care plans were essential to know "if resident goals, like remaining free of injury from the use of siderails, were met or not met." The nurse said Resident 145 "did not have a care plan for the use of siderails but should have."
The Director of Nursing confirmed the facility's policy was not followed.
Another resident faced mounting physical therapy refusals without proper intervention. Resident 147, admitted with a hip fracture and rheumatoid arthritis, had "good rehab potential" according to medical records. Doctors ordered daily physical therapy five days per week for 30 days.
Instead, the resident repeatedly refused treatment. Records show refusals on December 12, 13, 16, and 17, 2024, and again on January 10, 2025. On December 12, staff noted the resident "refused treatment even with max encouragement." The next day: "refused treatment family present and unable to encourage resident to participate in therapy."
During an inspection observation on January 30, Physical Therapist 1 asked the resident to change position from lying to sitting on the side of the bed. The therapist helped the resident sit up, but Resident 147 stated "she wants to lie back down in the bed" and refused to continue treatment.
The physical therapist warned that multiple missed sessions could lead to "stiffness, atrophy of the legs, loss of muscle strength, loss of sitting balance and tolerance, and at risk for skin breakdown if the resident is in bed all the time."
Despite discussions at interdisciplinary team meetings on December 10 and 17, staff never developed a care plan addressing the therapy refusals. An MDS nurse told inspectors "they should have developed the care plan when the resident had multiple refusals" but acknowledged "this was not done."
The Director of Nursing said the team "should have discussed with the son and should have been written" and noted "there is a potential for the resident's continuous refusal to result in a decline in their functional level."
A fourth resident, 86-year-old with chronic kidney disease, major depression, and dementia, was using a specialized pressure-relieving mattress without proper oversight. The Low Air Loss Mattress was set incorrectly for months, according to staff.
Certified Nursing Assistant 4 told inspectors the mattress "will alarm every 15 minutes so he sets the LALM settings beyond the resident's weight." The aide said he "usually sets it at maximum" to prevent the alarm and had "been going on for about 3 months now."
The CNA said he had informed a previous charge nurse but hadn't told current staff. When inspectors checked, they found no physician order for the specialized mattress and no care plan governing its use.
The Director of Nursing explained that such mattresses are for residents with "multiple pressure ulcers or have a high risk for development of pressure ulcers." She said treatment nurses should place stickers indicating proper settings "so everyone would know" and that nursing assistants "cannot manipulate the LALM settings."
The facility also failed to update care plans when conditions changed. Resident 62, who fell on an outside patio shortly after readmission in January, required supervision while smoking according to a January 6 evaluation. But his care plan continued to state he "may smoke independently" even after the fall assessment showed he needed supervision due to fall risk.
The Assistant Director of Nursing acknowledged the smoking care plan "was not updated to indicate the resident required supervision while smoking, but it should have been." She warned that failing to update the plan "could have resulted in the resident not being supervised while smoking and potentially leading to injury from falls and burns."
Facility policy required care plans to be reviewed and revised when residents experienced significant changes in condition. The comprehensive care plan policy, last reviewed January 22, 2025, stated plans must "incorporate identified problem areas" and "reflect treatment goals, timetables, and objectives in measurable outcomes."
The policy specifically required care plans to be updated "when there has been a significant change in the resident's condition" and "when the resident has been readmitted to the facility from a hospital stay."
All violations were classified as causing minimal harm or potential for actual harm, affecting multiple residents throughout the 102-bed facility on North Alexandria Avenue.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alexandria Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
