Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency House Of Alexandria during CMS and state inspections, most recent first.
Grievance Policy and Documentation Deficiencies: The facility did not have a grievance policy that identified a Grievance Official or included contact information for filing grievances, and it did not maintain evidence of grievance outcomes for the required retention period. Two residents had complaints reported by their RPs, including food consistency concerns and issues with a call light, toilet, bed remote, and room cleanliness, but these grievances were not documented in the grievance log. The ADM stated complaints were written on sticky notes and discarded after being corrected.
Failure to care plan oxygen use and hospice services: Two residents had physician orders and clinical diagnoses requiring specific care planning, but their care plans lacked documented evidence for those needs. One resident had COPD and an O2 order for 2 L/min via NC with weekly tubing/mask changes, and another resident had hospice orders for protein-calorie malnutrition; staff confirmed both care plans should have been present.
A resident with intact cognition and diagnoses including a lumbar fracture and type 2 DM had a care plan that listed full code, while the LaPOST showed DNR. The medical record did not contain an advance directive order, and the ADON confirmed the code status in the care plan was incorrect.
Medication Administration Did Not Match Physician Order: An RN administered the wrong Duloxetine dose to a resident with MDD and GAD, giving a 60 mg blister-pack medication even though the physician order was for 30 mg and the 60 mg dose had been discontinued. The eMAR documented 30 mg, but the RN later confirmed the blister pack read 60 mg and that she had given it to the resident.
Failure to Provide Ordered 1:1 Supervision: A resident with traumatic subdural hemorrhage, severe dementia with psychotic disturbance, and a history of combative and wandering behaviors had physician orders and a care plan for 1:1 supervision, including line-of-sight while sleeping. Survey observations found the resident sitting in the day area, at a dining table with other residents, and at the end of a hallway without supervision, and the ADON and Corporate Nurse confirmed the resident should have been on 1:1 but was not.
Respiratory equipment was not properly labeled for a resident with COPD, pneumonia, CHF, and CKD who was receiving O2 at 2 L/min via NC. The resident’s oxygen tubing and oxygen canister were observed undated, and the resident did not know when the tubing had last been changed. An IP nurse confirmed the items should have been dated.
Missing License Verification for Newly Hired LPN: The facility failed to verify a Louisiana nursing license prior to hire for an LPN who had just started working and was still orienting. The LPN reported being assigned residents while waiting for a computer login, and HR confirmed the license verification was not in the employee record before hire.
The facility failed to complete an annual performance review for 1 CNA whose record was reviewed. The CNA had an initial performance review, but the HR staff member confirmed no annual review was in the file even though one should have been completed.
Failure to post daily nurse staffing information: A Staff Reporting Form for licensed and unlicensed nursing staff directly responsible for resident care was not posted at the beginning of each shift. Observations showed an outdated form remained posted at the nurse's station while current forms were missing, and the ADON confirmed the required daily posting had not been done.
Puree Diet Recipes Not Followed: The facility failed to follow standardized puree recipes for two residents on pureed diets. During observation, an S3DM prepared pureed cabbage, pinto beans, and fried pork chops using bread and unmeasured water, despite the facility policy and recipes stating that water should not be used and that approved ingredients such as broth, gravy, or thickener should be used instead. The S3DM confirmed the recipes were not followed and said the recipes were not readily available to kitchen staff.
Undated open food items were found in the pantry and refrigerator, including brown gravy mix, potato chips, and sliced ham. S3DM confirmed that opened food items should be labeled with the date opened, but these items were not dated.
A resident with ESBL, dysphagia, a G-tube, and MDRO history had orders for EBP during high-contact care and continuous tube feeding, but PPE was not available or used as required. An ADON entered the room without PPE to adjust the bed and pillows, and a ST provided oral care and therapy wearing gloves only, with no EBP sign or PPE bin outside the room. The resident also had an undated peripheral IV site that was not changed within the required timeframe.
A resident with multiple chronic conditions did not receive their prescribed PRN Hydrocodone-Acetaminophen due to the medication not being available. An LPN borrowed the same medication from another resident and administered it, contrary to facility policy and professional standards. The incident was observed by staff and family, and confirmed by the DON and RN Supervisor.
A resident with chronic pain and opioid dependence was left without prescribed Hydrocodone-Acetaminophen due to failures in medication ordering and communication among nursing staff. In response, an LPN administered Tylenol without a physician order and later borrowed pain medication from another resident, violating medication protocols. The resident's family raised concerns about pain management, and the resident was transferred to the hospital for pain control.
Two residents experienced injuries of unknown origin that were not reported to the state agency within the required two-hour timeframe. One resident had a suspected femoral fracture, and another had a fall resulting in a scalp laceration. The facility's policy on reporting such injuries was not followed, and the Administrator's misunderstanding of reportable incidents contributed to the delay.
A resident with a history of Alzheimer's and Osteoarthritis experienced a failure in pain management when a CNA did not report the resident's complaint of leg pain to the nurse, despite being trained to do so. The resident's care plan required CNAs to report any pain complaints, but the CNA did not comply, as the resident requested not to inform the nurse. The CNA later acknowledged the oversight, and the CNA Supervisor confirmed the expectation to report all pain complaints.
An LPN failed to administer and accurately document medications for a resident, administering only 14 out of 18 scheduled pills. The LPN did not administer certain medications due to claimed unavailability and forgot others, yet documented them as given. Investigation revealed that some medications were available on the cart, and the DON confirmed they should have been administered per physician's orders.
A facility failed to provide pharmaceutical services by not ensuring the timely acquisition and administration of Sacubitril-Valsartan for a resident with congestive heart failure. The medication was not available during a scheduled administration, and although it was documented as given, it was confirmed by an LPN that it was not administered. The medication was not found on the cart or in storage, and an order was not released due to insurance denial, leading to the resident running out of the medication.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 11.76%. An LPN administered only 14 out of 18 prescribed pills to a resident, missing Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN documented these as administered despite admitting to not giving them due to unavailability and oversight. The DON confirmed the discrepancies, noting that the medications should not have been documented as given if not administered.
The facility failed to implement Enhanced Barrier Precautions for a resident with wounds and another with a PICC line, as staff did not wear appropriate PPE during care. Additionally, the facility did not test its water system for Legionella, as required by its infection control program.
A resident with a history of hemiplegia and irritable bowel syndrome requested an incontinent wipe from a CNA, which was refused. The CNA cited inappropriate behavior by the resident as the reason for refusal, despite the resident's frequent requests due to feeling unclean. The incident was reported by the resident's niece and confirmed by the resident's private sitter, highlighting a deficiency in respecting the resident's rights to dignity and self-determination.
A resident with intact cognition and multiple health conditions was found to be wearing the same pair of jeans for a week due to the facility's failure to return his other pants from the laundry. The resident's closet contained minimal clothing, and staff were unaware of the issue. The facility's administrator acknowledged the oversight, noting the absence of a Social Service Director may have contributed to the situation.
A resident with moderate cognitive impairment experienced an unwitnessed fall, and the facility failed to promptly notify the physician and responsible party. The LPN on duty assessed the resident but did not follow protocol to inform the necessary parties immediately, leading to a delay in notification until the following day. The facility's procedures for handling falls were not adhered to, as confirmed by the DON.
A facility failed to ensure proper wound care for a resident with a stage 3 sacral pressure sore. A CNA applied Zinc Oxide cream, a task reserved for nurses, contrary to the resident's care plan and physician's orders. The resident's care plan required specific wound management, but the cream was improperly left in the room and applied by unqualified staff, as confirmed by the DON.
A facility failed to adhere to professional standards for respiratory care by not changing a resident's oxygen tubing as per the prescribed schedule. The resident, who required continuous oxygen therapy due to respiratory failure and other conditions, had tubing dated over a week old, contrary to the facility's policy and physician's orders. An LPN confirmed the oversight during an interview.
A resident with moderate cognitive impairment and multiple medical conditions was found with a tube of Zinc Oxide ointment and a bottle of Nystatin powder left unattended on their bedside dresser. These medications were not currently prescribed, and staff confirmed they should have been secured in the medication cart. The resident did not have a physician's order to keep medications at the bedside, nor an assessment for self-administration.
The facility failed to properly dispose of garbage and refuse, as observed with a blue dumpster outside the kitchen surrounded by dirty gloves and debris. The Dietary Manager confirmed the findings, and the Maintenance Director stated the trash was left by sanitation employees. The Administrator confirmed the Maintenance Director's responsibility for maintaining cleanliness around the dumpster.
The facility failed to use proper signage for two residents on Transmission-Based Precautions due to COVID-19. Observations showed signage for Enhanced Barrier Precautions instead, confirmed by the RN Infection Preventionist. Both residents required isolation and substantial assistance with daily activities.
A facility failed to implement a care plan for monitoring the side effects and effectiveness of an anticoagulant medication for a resident with multiple diagnoses, including chronic atrial fibrillation and end-stage renal disease. Despite the care plan's directives, no monitoring was in place, as confirmed by interviews with staff.
The facility failed to follow physician's orders for weekly PT/INR tests and did not notify the physician of an abnormal PT/INR result for a resident on Coumadin. The resident had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical.
Grievance Policy and Documentation Deficiencies
Penalty
Summary
The facility failed to establish and maintain a grievance policy that identified a Grievance Official, included the Grievance Official’s contact information, and preserved evidence of grievance outcomes for at least 3 years from the issuance of the grievance decision. The facility’s policy titled Resident and Family Grievances, revised 09/01/2024, stated that a designated Grievance Official and contact information should be listed and that evidence of grievance results would be maintained for no less than 3 years, but the facility did not have those elements in place as confirmed by interview with the S1 ADM. Record review and interviews showed that grievances from 2 residents were not documented in the facility’s grievance log. Resident #2, admitted 04/21/2023 with diagnoses including Alzheimer’s Disease, Dementia, and Oropharyngeal Dysphagia, had an RP who reported meeting with the S1 ADM about the consistency of the resident’s food, but the February 2026 grievance log did not show this grievance. Resident #8, admitted 02/04/2026 with diagnoses including Metabolic Encephalopathy, Alzheimer’s Disease, Dementia, Anxiety, Major Depressive Disorder, and Abnormalities of Gait and Immobility, had an RP who reported complaints about the call light not being within reach, and the S1 ADM also stated the family had complained about the toilet not working, the bed remote not working, the toilet not being cleaned, and the call light not being within reach. The S1 ADM said he wrote complaints on sticky notes and discarded them after correcting the issue, and confirmed he did not maintain documentation of Resident #8’s grievances or evidence of the result of Resident #2’s grievance.
Failure to Care Plan Oxygen Use and Hospice Services
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered plan of care for Resident #34 related to oxygen use and for Resident #51 related to hospice services. Resident #34 was admitted with diagnoses including chronic obstructive pulmonary disease, pneumonia, acute on chronic diastolic congestive heart failure, and chronic kidney disease. Physician orders in March 2026 included changing the oxygen mask/nasal cannula and tubing weekly on the night shift every Wednesday and as needed, and oxygen at 2 liters per minute via nasal cannula for COPD, but the resident’s care plan contained no documented evidence related to oxygen use. Resident #51 was admitted with diagnoses including type II diabetes, moderate protein-calorie malnutrition, dysphagia, congestive heart failure, and anemia. Physician orders in March 2026 included admission to hospice for protein-calorie malnutrition, with an order dated 10/28/2025, but the resident’s care plan contained no documented evidence related to hospice services. During interview, the MDS/CP Nurse confirmed that Resident #34 should have had a care plan related to oxygen use and that Resident #51 should have had a care plan related to hospice service.
Care Plan Not Updated for Advance Directive Status
Penalty
Summary
The facility failed to ensure Resident #22’s comprehensive care plan was revised after a change in advance directive status. Resident #22 was admitted on 01/16/2026 with diagnoses including unstable burst fracture of the second lumbar vertebra, subsequent encounter for fracture with routine healing, and type 2 diabetes mellitus with diabetic nephropathy. The 5-day Medicare MDS showed a BIMS score of 14, indicating intact cognition. The care plan initiated on 01/20/2026 listed the resident’s advance directive as full code, while the Louisiana Physician Orders for Scope of Treatment (LaPOST) documented Do Not Resuscitate (DNR). The medical record did not reveal an order for an advance directive, and the ADON confirmed that the care plan showed full code but should have been DNR.
Medication Administration Did Not Match Physician Order
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not following a physician’s order for Resident #10. The resident had diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder. Facility policy stated that medications are to be administered as ordered by the physician and in accordance with professional standards of practice, with staff to review the MAR and compare the medication source with the MAR to verify the dose. During observation on 03/03/2026 at 8:21 a.m., an RN administered medications to Resident #10 and placed 8 tablets into a medication cup. The RN compared the blister packs to the MAR on screen and gave Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 mg. However, the resident’s physician orders showed Duloxetine HCl 30 mg and that the 60 mg dose had been discontinued on 02/03/2026. The eMAR documented that the RN administered Duloxetine HCl 30 mg, but during interview the RN reviewed the blister pack with the surveyor and confirmed the blister pack read Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 mg and that she had administered it to the resident that morning.
Failure to Provide Ordered 1:1 Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who had orders for 1:1 supervision. Resident #7 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, major depressive disorder, unspecified severe dementia with psychotic disturbance, and other Alzheimer disease. The resident’s record showed a BIMS score of 08, indicating moderate cognitive impairment. Physician orders in the record included 1:1 supervision while awake and line of sight supervision while sleeping, with reevaluation every 24 hours for continued supervision needs, and a later order for 1:1 supervision every shift for behaviors. The care plan identified risks related to cognitive deficits, violent behavior toward staff, wandering, combative behavior, verbal abuse, and refusal of care, with 1:1 supervision initiated for these concerns. Despite these orders and care plan interventions, observations showed Resident #7 sitting in the day area in a wheelchair without supervision, being left alone after a staff member helped him back into the wheelchair, sitting at a dining table with two other residents without supervision, and sitting alone at the end of a hallway in a wheelchair. During interview, the ADON confirmed the resident was left unsupervised and stated he should not have been. The Corporate Nurse stated the resident’s 1:1 supervision was revised to reflect 1:1 at all times, including sleeping hours, and confirmed the resident should have been on 1:1 supervision but was not.
Respiratory Equipment Not Properly Labeled
Penalty
Summary
Provide safe and appropriate respiratory care when needed was not met for Resident #34, who was admitted with diagnoses including COPD, pneumonia, acute on chronic diastolic CHF, and CKD. The resident had a physician order for oxygen at 2 liters per minute via nasal cannula and for the oxygen mask/nasal cannula and tubing to be changed weekly on Wednesday nights and as needed. During observation, the resident was sitting on the side of the bed with oxygen infusing via nasal cannula, and the oxygen tubing and oxygen canister were undated. The resident stated she did not know when the oxygen tubing had been changed. An IP nurse later confirmed that the oxygen tubing and oxygen canister were not dated but should have been.
Missing License Verification for Newly Hired LPN
Penalty
Summary
The facility failed to ensure nursing staff had the appropriate knowledge and skill sets to provide care and respond to each resident's individualized needs as identified in assessment and care plans. Record review showed that the facility did not verify the presence of a Louisiana nursing license prior to hire for 1 of 2 licensed nurses reviewed, an LPN who began working in the facility on 03/02/2026. During interview, the LPN stated she was supposed to be orienting with a nurse who was pulled to do treatments, had been orienting with an RN who was then reassigned to resident treatments, was assigned residents, and was waiting for a computer login. Review of the LPN's employee record showed a hire date of 03/02/2026, but no verification of a Louisiana nursing license prior to hire. The HR staff member stated that verification of Louisiana nursing licenses was printed and placed into the employee record of all licensed nurses prior to hire, and confirmed the facility did not have verification of this LPN's Louisiana nursing license prior to hire.
Missing Annual Performance Review for CNA
Penalty
Summary
The facility failed to ensure an annual performance review was completed for 1 CNA whose employee record was reviewed. Review of the CNA's record showed a hire date of 09/16/2024, and further review did not reveal an annual performance review. During interview, the HR staff member confirmed the CNA had an initial performance review on 02/24/2025 but did not have an annual performance review, although one should have been completed.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing data for licensed and unlicensed nursing staff directly responsible for resident care on a daily basis at the beginning of each shift. On 03/03/2026 at 9:32 a.m., observation revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. During interview on 03/03/2026 at 9:34 a.m., the ADON stated the Staff Reporting Form was to be posted daily at the beginning of each shift and confirmed the form for 03/03/2026 had not been posted, although it should have been. Later that day at 4:02 p.m., observation again showed only the 03/02/2026 form posted, with no form dated 03/03/2026. On 03/04/2026 at 8:11 a.m. and again at 11:11 a.m., the same 03/02/2026 form remained posted, and the forms dated 03/03/2026 and 03/04/2026 were not posted.
Puree Diet Recipes Not Followed
Penalty
Summary
The facility failed to ensure that planned menus and standardized puree recipes were followed for residents requiring a pureed diet. A policy revised 09/01/2024 stated that puree foods were to be prepared to conserve nutritive value and that water was not to be used as an additive. The policy also listed puree preparation guidelines, including using beef broth or gravy for meats and mashed potato flakes for certain vegetables. During observation on 03/02/2026, S3DM prepared pureed cabbage by adding several scoops of cabbage, three pieces of bread, and an unmeasured amount of water into a food processor, then processed it to a pudding-like consistency. The same observation showed S3DM preparing pureed pinto beans by adding several scoops of beans, three pieces of bread, and an unmeasured amount of water, and pureed fried pork chops by adding several pieces of pork chops, four pieces of bread, and an unmeasured amount of water. Review of the recipes for pureed cabbage, beans, and fried pork chops stated to measure servings using the regular prepared recipe portion, drain well, add liquid if needed using reserved liquid, broth, milk, gravy, or sauce, and not use water as the liquid when preparing puree foods. During interview, S3DM confirmed the standardized recipes were not followed, stated the recipes were not readily available to kitchen staff and would need to be printed, and acknowledged that water and bread should not have been used.
Undated Open Food Items in Pantry and Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not ensuring that open food items in the pantry and refrigerator were labeled with the date they were opened. During an observation on 03/02/2026 at 6:08 a.m., surveyors found one undated open package of brown gravy mix, one undated open bag of potato chips, and one undated open package of sliced ham in the pantry and refrigerator. At 6:20 a.m., S3DM confirmed that all opened food items stored in the pantry or refrigerator should be labeled with the date the item was opened, and confirmed that the items observed should have had an open date but did not.
Failure to Follow EBP and IV Site Management
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #49, who had diagnoses including Extended Spectrum Beta Lactamase Resistance, Dysphagia, Gastrostomy Status, Resistance to Multiple Antibiotics, and Cognitive Communication Deficit. The resident had physician orders for Enhanced Barrier Precautions during all high-contact resident care and for enteral feeding of Jevity 1.5 at 50 mL/hr via pump. During observation, tube feeding was infusing, but no gowns or masks were noted inside the resident’s room or outside the door. An undated IV site was also observed on the distal dorsal surface of the resident’s left arm. Staff observations showed that Enhanced Barrier Precautions were not followed during direct care. The S2 ADON entered the resident’s room without PPE, adjusted the head of the bed, and repositioned pillows, and later confirmed the resident was ordered for EBP and that PPE should have been donned before direct care. A speech therapist entered the room wearing gloves only and performed oral care and speech therapy while leaning over the resident and against the bedding; she confirmed there was no EBP sign on the door and no PPE bin outside the room. The IP later confirmed staff should have worn gown and gloves for high-contact care, and that the resident’s IV should have been dated and removed after 72 hours, but was not.
Failure to Administer Ordered Controlled Medication and Improper Borrowing of Medication
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that controlled medications ordered for a resident were administered as prescribed. Specifically, the resident had a physician's order for Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for pain. However, due to the facility not having the resident's pain medication available, an LPN borrowed the same medication from another resident and administered it to the resident in need. This action was acknowledged by the LPN, who stated she knew it was not appropriate, and was confirmed by the Director of Nursing and RN Supervisor. The resident involved had multiple diagnoses, including COPD, Type II Diabetes Mellitus with neuropathy, severe dementia with agitation, opioid dependence, and anxiety disorder. The resident was cognitively intact and required some assistance with activities of daily living. The lack of medication availability was noted by staff over several days, and the improper administration of another resident's medication was observed and reported by staff and family members. The facility's policy required strict adherence to medication administration standards, including verifying the right resident and medication, which was not followed in this instance.
Failure to Ensure Timely Acquisition and Proper Administration of Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the timely acquisition and dispensing of a controlled medication, Hydrocodone-Acetaminophen, for a resident with multiple diagnoses including chronic pain conditions and opioid dependence. The resident was admitted with a prescription for Hydrocodone-Acetaminophen to be given as needed for pain, but the medication supply was depleted on 12/03/2025. The process for reordering the medication was not properly followed, as the empty medication card was left on the Assistant Director of Nursing's desk without direct communication, and the responsible staff did not ensure the order was placed or received. During the period when the resident was without his prescribed pain medication, staff attempted to manage his pain by administering Tylenol, for which there was no physician order, and later by borrowing Hydrocodone-Acetaminophen from another resident, which is a violation of medication administration protocols. Multiple staff interviews confirmed that the breakdown in communication and lack of clear responsibility for medication ordering led to the resident being without his PRN pain medication for several days. The resident's family became aware of the situation and expressed concern about neglect related to pain management. The resident ultimately required transfer to the hospital for pain management at the family's request. Documentation and interviews revealed that the facility's procedures for controlled substance administration and accountability were not followed, resulting in the resident not having access to his prescribed pain medication when needed. The failure to ensure the availability of the medication and the inappropriate borrowing of another resident's medication were directly observed and confirmed by staff and administrative personnel.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for two residents within the required two-hour timeframe as mandated by state law. Resident #1, who had a history of Alzheimer's disease and osteoarthritis, was found to have a suspected minimally displaced femoral peri arthroplasty fracture after complaining of knee pain. Despite receiving the x-ray results confirming the fracture, the facility did not report the injury within the required timeframe. The Administrator acknowledged the oversight, stating that the report should have been submitted immediately upon reviewing the x-ray results. Resident #2, who had diagnoses including protein calorie malnutrition and a history of falls, experienced an unwitnessed fall resulting in a laceration to the scalp and a subsequent emergency room visit. The RN on duty reported the incident to the Administrator shortly after it occurred, but the Administrator did not consider the fall a reportable injury at the time. It was only after the injury was revealed to be a fracture that the Administrator recognized it as a reportable incident. The facility's policy on reporting suspicious injuries of unknown origin was not followed in these cases, leading to a delay in notifying the state agency. The policy requires that all instances of serious bodily injury, such as fractures or head injuries, be reported within two hours. The Administrator's misunderstanding of what constitutes a reportable injury contributed to the failure to comply with state reporting requirements.
Failure to Report Resident's Pain Complaint
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, specifically in the area of pain management. The resident, who has a history of Alzheimer's Disease, Fibromyalgia, Osteoarthritis, and other conditions, was noted to have moderate cognitive impairment and required assistance with daily activities. The care plan included an intervention for Certified Nursing Assistants (CNAs) to monitor, record, and report any complaints of pain to the nurse. However, during an incident, a CNA did not report the resident's complaint of leg pain to the nurse, as the resident requested not to inform the nurse. The CNA, despite being trained to report any signs of pain regardless of the resident's request, failed to notify the nurse about the resident's pain complaint. This was confirmed during an interview with the CNA, who acknowledged the oversight. The CNA Supervisor also confirmed that the expectation was for all pain complaints to be reported to the nurse, even if the resident advised otherwise. This failure to report the pain complaint was a deviation from the established care plan and facility policy on pain management.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring medications were administered and accurately documented for a resident during medication administration. An LPN administered 14 pills to a resident, while the Medication Administration Record (MAR) indicated that 18 pills were scheduled to be administered. The LPN confirmed that she did not administer Bactrim DS, Sacubitril-Valsartan, or Sodium Bicarbonate due to their unavailability and forgot to administer Cyanocobalamin. Despite this, she documented the medications as administered, intending to correct the documentation later. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Director of Nursing confirmed that these medications, along with Cyanocobalamin, should have been administered according to the physician's orders. Additionally, there was a discrepancy in the documentation of Bactrim DS administration, as the blister pack indicated fewer pills were removed than documented in the MAR.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the timely acquisition, receipt, and administration of Sacubitril-Valsartan, a non-controlled medication prescribed for congestive heart failure. During a medication administration observation, it was noted that the medication was not available and was not administered to the resident, despite being documented as given. The Licensed Practical Nurse (LPN) involved confirmed that the medication was not administered because it was unavailable and admitted to documenting it as administered by mistake. Further investigation revealed that the medication was not present on the medication cart, in the resident's cubby, or in the Pixus. The facility's records showed that the last supply of the medication was received on January 20, 2025, and the resident would have run out by February 3, 2025. An order for the medication was created on January 30, 2025, but was not released due to an insurance denial. The facility's Director of Nursing (DON) and other staff confirmed the medication was not available and that there was no follow-up to address the missing medication, despite it being documented as administered by nursing staff.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 11.76% during a survey. Specifically, the facility did not administer all prescribed medications to a resident as per the physician's orders. During a medication administration observation, an LPN administered only 14 out of the 18 prescribed pills to a resident. The missing medications included Bactrim DS, Sacubitril-Valsartan, Sodium Bicarbonate, and Cyanocobalamin. The LPN admitted to not administering these medications due to unavailability and oversight, yet documented them as administered. Further investigation revealed that the Bactrim DS and Sodium Bicarbonate were available on the medication cart, contradicting the LPN's claim of unavailability. The Sacubitril-Valsartan was not found on the cart or in storage, and the resident had reportedly run out of this medication days prior, despite it being documented as administered. The DON confirmed the discrepancies and acknowledged that the medications should not have been documented as given if they were not administered. This series of actions and inactions led to the facility's failure to adhere to its medication administration policy and maintain an acceptable medication error rate.
Infection Control Deficiencies in EBP and Water Testing
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer and a diabetic ulcer, as required by their policy. Despite the resident's condition necessitating EBP, there was no order for these precautions, and no signage or personal protective equipment (PPE) was available in or outside the resident's room. The resident's wife was not educated on infection control precautions, and staff did not wear appropriate PPE during toileting care, as observed by surveyors. Another resident, who had a PICC line and required EBP for high-contact care activities, did not receive proper care as staff failed to wear gowns during incontinent care. Although the resident's room had a red dot indicating the need for EBP, staff did not comply with the PPE requirements. Interviews with staff confirmed that they were aware of the EBP requirements but failed to adhere to them during care. Additionally, the facility did not maintain an infection prevention and control program as it failed to test the water system for Legionella. The facility's water management program required measures to minimize the risk of Legionella, but there was no documented evidence of testing since September 2024. The administrator confirmed that the facility had not conducted the necessary testing, which is a critical component of their infection control program.
Failure to Honor Resident's Request for Incontinent Wipe
Penalty
Summary
The facility failed to honor a resident's right to request an incontinent wipe, which is a violation of the resident's rights to dignity and self-determination. The incident involved a resident with a history of hemiplegia, major depressive disorder, anxiety disorder, and irritable bowel syndrome, who was dependent on assistance for toileting hygiene. The resident, who had a BIMS score indicating intact or mildly impaired cognition, requested an incontinent wipe from a CNA, which was refused. The CNA stated that the resident had already been cleaned and did not provide the wipe, citing inappropriate behavior by the resident with the wipe as the reason. The incident was reported by the resident's niece to the facility administrator, who confirmed the refusal of the request. The resident's private sitter corroborated the account, stating that the CNA told the sitter to provide the wipe if desired. The refusal to provide the wipe was confirmed by the CNA during an interview, acknowledging that the resident often requested wipes because she did not feel clean. This failure to provide the requested wipe was identified as a deficiency in treating the resident with respect and dignity, as required by federal and state law.
Resident Lacks Adequate Clothing Due to Facility Oversight
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #205, was treated with respect and dignity by not providing adequate clothing. Resident #205, who was admitted with diagnoses including Major Depressive Disorder, Type 2 Diabetes Mellitus, Acute Respiratory Failure, and Unspecified Protein Calorie Malnutrition, had a BIMS score of 15, indicating intact cognition. The resident required assistance with dressing and had been wearing the same pair of jeans for a week, as his other pair of pants, provided by the facility, had not been returned from the laundry. The resident expressed feeling bad about not having clothes and had informed two employees about the missing joggers but received no response. Observations and interviews revealed that the resident's closet contained only a pack of white t-shirts, socks, underwear, and a coat, with no other clothing items. The LPN providing care for the resident was unaware of the situation, and the Acting Social Service Director was also not informed about the resident's lack of clothing. The facility's administrator acknowledged purchasing some basic clothing items for the resident but confirmed that the facility should have assisted further in obtaining appropriate outerwear. The absence of a Social Service Director at the time may have contributed to the oversight.
Failure to Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly notify the physician and responsible party after a change in a resident's condition, specifically following an unwitnessed fall. Resident #49, who was admitted with diagnoses including vascular dementia and moderate cognitive impairment, experienced a fall on 02/08/2025. The fall was reported to S10 Medical Records LPN by S8 CNA, who found the resident sitting upright on the floor with his back against his wheelchair. Although S10 Medical Records LPN conducted a head-to-toe assessment and documented the incident in the progress notes, she did not notify the physician or the resident's responsible party immediately as required. The delay in notification was confirmed during interviews with the staff, including S10 Medical Records LPN, who admitted to not notifying the necessary parties due to being overwhelmed with other tasks. The Director of Nursing (S2 DON) confirmed that the facility's protocol requires immediate notification of the physician and responsible party following a fall, which was not adhered to in this case. The notification was eventually made by another LPN the following day, and the incident report was back-dated, indicating a lapse in the facility's adherence to its own procedures for handling resident falls.
Improper Wound Care by CNA
Penalty
Summary
The facility failed to ensure that services provided to Resident #206 were delivered by individuals with the appropriate skills and qualifications, as outlined in the resident's plan of care. Specifically, S6 CNA applied Zinc Oxide cream to Resident #206's stage 3 sacral pressure sore, which was against the facility's protocol that only nurses are allowed to perform wound care. Resident #206, who was cognitively intact and required various levels of assistance for daily activities, had a care plan that included specific interventions for a stage 3 pressure ulcer. The physician's orders required cleansing the ulcer and applying Zinc Oxide, but this task was improperly performed by a CNA instead of a nurse. Observations and interviews revealed that the Zinc Oxide cream was left in Resident #206's room, and S6 CNA confirmed applying it during toileting care. The Director of Nursing (S2 DON) acknowledged that CNAs are not permitted to apply Zinc to wounds and confirmed that the cream should not have been left in the resident's room. Further observation of Resident #206's care showed a reddened, uncovered stage 3 pressure ulcer, indicating a lack of proper wound management as per the care plan and physician's orders.
Failure to Adhere to Oxygen Equipment Change Schedule
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident, identified as Resident #156, who required continuous oxygen therapy. The facility's policy mandated that oxygen tubing and mask/cannula be changed weekly and as needed if soiled or contaminated. However, observations revealed that Resident #156's oxygen tubing, dated 01/29/2025, had not been changed as per the physician's orders, which specified a change every Wednesday night shift and as needed. This oversight was confirmed during an interview with an LPN, who acknowledged that the tubing should have been changed but was not. Resident #156 was admitted with diagnoses including acute and chronic respiratory failure, chronic systolic heart failure, depression, anxiety disorder, and dependence on enabling machines and devices. The resident's medical record indicated intact cognition with a BIMS score of 14 and a requirement for continuous oxygen administration at 3 liters per minute. Despite these needs, the facility did not adhere to the prescribed schedule for changing the oxygen equipment, leading to a deficiency in the standard of care provided to the resident.
Medications Left Unsecured at Resident's Bedside
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by medications being left at the bedside of a resident. During an observation, a tube of Zinc Oxide ointment and a bottle of Nystatin powder were found unattended on the bedside dresser of a resident with moderate cognitive impairment and multiple medical conditions, including a stage 4 pressure ulcer and bipolar disorder. These medications were not prescribed for current use, as the orders for Zinc Oxide had been discontinued months prior, and the Nystatin powder order had been completed weeks before the observation. Interviews with facility staff confirmed that the medications should not have been left at the bedside and should have been secured in the medication cart when not in use. The resident did not have a physician's order to keep medications at the bedside, nor was there an assessment to determine if the resident was safe to self-administer medications. The Director of Nursing acknowledged that the medications should have been disposed of properly and confirmed that the resident does not self-administer medications.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed and confirmed by staff. During an inspection, a blue dumpster located outside the facility's kitchen was found surrounded by dirty gloves and debris, including old cardboard boxes. This observation was confirmed by the Dietary Manager at the time. The Maintenance Director indicated that the trash was left by sanitation employees, and the Administrator confirmed that the Maintenance Director was responsible for ensuring the area around the dumpster was kept clean.
Inadequate Signage for Transmission-Based Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the use of proper signage for residents on Transmission-Based Precautions. Two residents, identified as Resident #2 and #R1, were placed in isolation due to positive COVID-19 tests. However, observations revealed that the signage on their doors indicated Enhanced Barrier Precautions instead of the appropriate Transmission-Based Precautions. This discrepancy was confirmed by the RN Infection Preventionist during the survey. Resident #2 was admitted with diagnoses including COVID-19, a disorder involving the immune mechanism, atherosclerotic heart disease, and an acquired absence of the right leg below the knee. The resident required varying levels of assistance with daily activities. Similarly, #R1 was admitted with diagnoses including COVID-19, rhabdomyolysis, cerebral infarction, unspecified dementia, and unspecified atrial fibrillation, and also required substantial assistance with daily activities. Despite their isolation status due to COVID-19, the incorrect signage was observed multiple times on their doors, indicating a failure in the facility's communication and implementation of appropriate infection control measures.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring side effects and effectiveness of an anticoagulant medication. Resident #3, who had diagnoses including gastrointestinal hemorrhage, anal fissure, chronic atrial fibrillation, end-stage renal disease, and dependence on renal dialysis, was admitted with a care plan that required monitoring for side effects and effectiveness of Warfarin therapy every shift. However, a review of Resident #3's medical record revealed no such monitoring was in place, despite the care plan's directives. Interviews with S2 RN and S1 DON confirmed that no monitoring had been implemented to assess for possible side effects and effectiveness of Resident #3's anticoagulant therapy. This lack of monitoring was a direct violation of the resident's care plan, which specified the need for such assessments to be conducted every shift. The deficiency was identified during a review of the resident's significant change MDS, which indicated intact cognition and various dependencies for daily activities.
Failure to Follow Physician's Orders for Lab Tests and Notify Physician of Abnormal Results
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of practice for Resident #3. Specifically, the facility did not follow physician's orders for obtaining labs for a medication that required a drug level. Resident #3 had orders for a weekly PT/INR test due to being on Coumadin for Atrial Fibrillation. However, the PT/INR test was not conducted weekly as ordered, with a gap from 02/01/2024 to 02/20/2024. Additionally, an abnormal PT/INR result was obtained on 12/06/2024, but there was no documentation that the Medical Director was notified when the attending physician did not immediately respond to the abnormal result. Interviews with the nursing staff confirmed that Resident #3's weekly PT/INR tests were not consistently obtained and that there was a failure to follow up with the physician regarding the abnormal test result. The Director of Nursing also confirmed that the orders for the weekly PT/INR were not followed and that there was no follow-up with the physician for the abnormal test result. Resident #3 had a history of gastrointestinal hemorrhage, chronic atrial fibrillation, and end-stage renal disease, making the monitoring of PT/INR levels critical for their care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 118 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Summit | 1.1 mi | ★★★★★ | 10 | 0 |
| Belle Grande Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 9 | 0 |
| Lexington House | 2.5 mi | ★★★★★ | 3 | 0 |
| Matthews Memorial Health Care Center | 3.5 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing At St. Christina | 4.5 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Regency House Of Alexandria.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.