Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alexandria Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease, and a history of multiple falls experienced repeated unwitnessed falls despite being care-planned for various fall-prevention measures. The care plan did not include ordered bed and chair alarms, and individualized fall interventions were limited and inconsistently implemented, with no documented hourly checks before the resident sustained a left hip fracture. Staff on the memory care unit reported that the resident was known to wander and attempt unassisted toileting at night, yet CNAs were unaware of any specific frequent monitoring requirements, and at times only one CNA was present on the unit while the nurse was assigned elsewhere. Assignment sheets listed hourly visual checks, non-skid footwear, and non-skid strips at bedside, but surveyors and the corporate nurse consultant confirmed that non-skid strips were not in place beside the resident’s bed. The facility also lacked a fall prevention policy addressing adequate supervision, and leadership acknowledged that supervision issues related to falls were not identified during root cause analyses.
A facility failed to ensure appropriate GDR attempts and continued justification for antipsychotic use for two residents. One resident with dementia, anxiety, depression, and psychosis remained on quetiapine after a GDR attempt and pharmacy recommendation, despite records showing confusion, tearfulness, restlessness, and repeated requests for family or to leave. Another resident with dementia, depression, and psychosis was treated with risperidone after a dose reduction, while the chart documented tearfulness, hallucinations, confusion, and episodes of aggression, and staff were uncertain whether the behaviors were dementia-related or hallucinations.
Missing Written Transfer/Discharge Notices and Bed Hold Information: The facility did not consistently document that residents or their representatives received written transfer/discharge appeal rights and bed hold policy information during hospital or psych transfers. Records for several residents with acute changes, including dementia, CHF, respiratory failure, CKD, and a femur fracture, showed transfer paperwork and EMT involvement, but the required written notices were absent or incomplete, and one resident's record also lacked communication to the receiving facility.
A facility failed to administer PRN hydralazine per MD orders for two residents with HTN and severe cognitive impairment. Both residents had repeated systolic BP readings above the ordered threshold of 165, yet the medication was not given on multiple occasions. The DON stated the NP had provided instructions to recheck BP before hydralazine use and to document the rechecks, but she was unsure whether those instructions were being followed or documented.
A resident with dementia, depression, anxiety, psychosis, vomiting, and underweight status had significant weight loss and required supervision/cueing with eating. The dietitian noted >10% weight loss in 6 months and recommended stopping Boost at meals to promote intake, changing Boost Plus to BID, and adding Boost Breeze daily, but staff continued giving supplements at meals and the resident was observed receiving white milk instead of ordered chocolate milk. The DON said the recommendations were discussed with the NP, but no documentation was provided explaining why the dietitian’s recommendation to not give Boost at meals was not followed.
Unlocked Medication Cart Left Unattended: An LPN inadvertently left a medication cart unlocked and unattended in a hallway, with keys in her pocket. The cart contained medications for 19 residents and remained unsecured until the LPN returned and locked it. The DON stated that medication carts should be locked when not in use, and the facility policy required drug storage areas and devices to be kept locked when not attended.
A CNA handled a resident's hamburger sandwich with bare hands while cutting it in the dining room, placing her fingertips on the top bun as she used a knife to divide it. The CNA later acknowledged she should not have touched the food barehanded, and the DON stated staff were not to touch residents' food with bare hands. Facility policy required that ready-to-eat food not be touched with bare hands and that gloves be worn.
A resident with multiple medical conditions was mistakenly administered naloxone nasal spray instead of the prescribed buprenorphine-naloxone sublingual film by an LPN, resulting in hospitalization for altered mental status and cardiogenic shock. The error occurred due to confusion between medication forms and a failure to follow medication administration protocols, including proper verification of the medication and route.
The facility failed to monitor vital signs per physician orders before administering medications to three residents. One resident received metoprolol despite low systolic blood pressure, another received losartan with blood pressure below the required level, and a third received metoprolol without recorded heart rates. Interviews revealed that the facility's system requires vital signs entry before medication administration, but this was not adhered to, resulting in the deficiency.
A resident with Alzheimer's and dementia was observed dining in a wheelchair too low for the table, requiring her to place her food bowl in her lap. Despite staff awareness, no effective interventions were implemented, and the facility lacked a dining policy.
A facility failed to update the PASRR for a resident with new mental health diagnoses, including schizophrenia and major depressive disorder. Despite significant changes in the resident's mental health status, the PASRR was not updated to reflect these new conditions. The oversight was identified during a review, and staff acknowledged the lapse, noting the absence of a specific policy for PASRR Level I.
Failure to Provide Adequate Supervision and Individualized Fall Interventions for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure adequate supervision and individualized fall interventions for a cognitively impaired resident with a known history of multiple falls. The resident had diagnoses including Alzheimer’s disease, a displaced intertrochanteric fracture of the left femur, insomnia, trigeminal neuralgia, and anxiety, and was taking memantine and carbamazepine. A quarterly MDS showed the resident was severely cognitively impaired, required staff assistance for most ADLs, and had experienced two or more prior falls. The resident’s care plan identified a fall risk problem related to history of falls, unsteadiness, and poor safety awareness, with interventions such as non-skid footwear, non-skid strips at bedside, clutter-free pathways, hourly visual checks, scheduled toileting at 4:00 a.m., night light, low bed position, motion detector at bedside, and remaining in common areas after meals. However, the care plan did not include interventions for the ordered bed alarm and chair alarm, and other care plan problems related to dependence in ADLs and wandering had not been updated since February despite ongoing falls. From November through April, the resident experienced multiple falls, many unwitnessed, with repeated documentation of wandering without regard to fatigue or hunger. Falls occurred in the bedroom, in front of the restroom, in the dining room, in front of a recliner, near a tipped-over roommate’s walker, beside the bed, in front of a glider/rocker, and in the restroom. Immediate post-fall actions were generally limited to assisting the resident back to bed or toilet, performing neuro checks, or providing brief education, and IDT notes often listed generic or environmental causes such as weakness, poor safety awareness, adjustment to new glasses, or incontinence. New interventions added after these falls were frequently broad or environmental (e.g., hourly visual checks, assistance to bathroom at a set time, clear pathways, provider evaluation, motion detector at bedside, resident to remain in dining room after meals) and the record lacked evidence of individualized, resident-specific fall-prevention strategies beyond these measures. The clinical record specifically lacked an individualized intervention related to falls prevention after the 1/20/26 fall, and there was no documentation of hourly checks being completed as care-planned prior to the resident’s hip fracture. On 2/25/26, the resident sustained an unwitnessed fall at the doorway of her room during night shift, was found on the floor with bare feet and left hip/leg pain, and was diagnosed with a left hip fracture requiring surgical repair. At the time of this fall, the Memory Care Unit was typically staffed with one or two CNAs at night for 14 residents, and the nurse was assigned to other units. CNA 6 reported being the only aide on the Memory Care Unit when the fracture occurred and was in the shower room washing wheelchairs when the resident fell; the resident was later found sitting on the floor in the doorway of her room with the bed alarm sounding. Staff interviews revealed that the resident was known to wander at night and attempt unassisted toileting, but CNAs were not aware of any specific frequent monitoring requirements for her beyond general rounding every two hours per protocol. Assignment sheets listed hourly visual checks, non-skid footwear, and non-skid strips at bedside as interventions, yet surveyors observed that non-skid strips were not present beside the resident’s bed, and the Corporate Nurse Consultant confirmed their absence despite the care plan and assignment sheet. The facility’s own fall prevention policy required identification of at-risk residents and implementation of appropriate, individualized interventions, but the facility lacked a fall prevention policy specifically addressing adequate supervision, and the DON acknowledged that the facility should have been able to identify lack of supervision as a factor during root cause analyses of the resident’s repeated falls.
Unnecessary Psychotropic Medication Use and Inadequate GDR Documentation
Penalty
Summary
The facility failed to ensure that two residents prescribed antipsychotic medications had appropriate gradual dose reduction (GDR) attempts and continued indication for use when GDRs were attempted and considered unsuccessful without clinical justification. Resident 8 had diagnoses including Alzheimer’s disease, dementia, anxiety, major depressive disorder, and unspecified psychosis, and was receiving quetiapine 12.5 mg at bedtime. Her quarterly MDS showed severe cognitive impairment and no mood indicators or behaviors during the assessment period. Although a GDR had been attempted on 1/22/25 and the pharmacy recommended discontinuation, the medication was restarted after staff documented episodes of confusion, tearfulness, restlessness, and repeated requests for family or to leave. The record also showed multiple behavior memos describing the resident as upset, anxious, verbally aggressive, tearful, restless, or confused, with interventions such as reassurance, redirection, snacks, one-on-one attention, and family contact. Resident 12 had diagnoses including dementia with behavioral disturbance, major depressive disorder, Alzheimer’s disease, unspecified psychosis, and depression, and was receiving divalproex, risperidone, and sertraline. Her quarterly MDS indicated moderate cognitive impairment, disorganized thinking, inattention, and no mood indicators or behaviors marked. The care plan identified psychosis, anxiety, delirium risk, and dementia-related cognitive loss, but the psychosis care plan did not describe how the psychosis presented or how the resident expressed behaviors. The record contained behavior memos and nursing notes describing tearfulness, crying, anxiety, hallucinations, confusion, aggression during shower care, and repeated statements that other residents were family members or that she saw her parents. Staff documented that behavior sheets were intended for agitation and aggression, but not for regular confusion. The record showed a pharmacy recommendation for a GDR of risperidone, and the provider reduced the dose from 0.25 mg daily to 0.125 mg daily. The resident continued to have episodes documented as emotional, tearful, hallucinating, confused, and physically aggressive, including hitting a CNA and running a wheelchair over staff feet. During interviews, staff and the DON stated the behaviors could be related to dementia or hallucinations, and the DON was uncertain whether the behaviors were hallucinations or dementia-associated behaviors. The facility policy stated antipsychotics are generally used only for certain documented diagnoses and that GDRs should be considered to find the lowest effective dose, with observation and documentation of failed dose reduction if observed.
Missing Written Transfer/Discharge Notices and Bed Hold Information
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of transfer/discharge appeal rights and the bed hold policy for multiple hospital transfers, and it also failed to provide communication to the receiving health care facility for one resident. The deficiency involved Residents 6, 7, 22, and 57, all of whom had hospital transfers or emergency department transfers documented in the record, but the records did not consistently show that the required written notices were provided to the resident or representative at the time of transfer or within the required timeframe. Resident 7 had diagnoses including Alzheimer's disease, vascular dementia with agitation, dementia with agitation, unspecified dementia with other behavior disturbance, and major depressive disorder with psychotic symptoms. After becoming physically aggressive and throwing items in the room, a referral was sent to a psychiatric facility and the resident left the building with EMTs. The record showed transfer paperwork and a note that the family was aware, but it lacked documentation that the resident's representative was notified in writing of transfer/discharge appeal rights and the bed hold policy for the transfer. Resident 6 had diagnoses including chronic respiratory failure with hypoxia, congestive heart failure, and disorientation, and was transferred to the hospital on three separate occasions for acute changes including high heart rate, high blood pressure, confusion, incontinence, shortness of breath, wheezing, and elevated heart rate. Although the record contained transfer forms, notices of transfer or discharge, bed hold policy copies, and hearing request forms for each transfer, the documentation was incomplete in several areas and the record lacked documentation that the resident's representative was notified in writing of the transfer/discharge appeal rights and bed hold policy at the time of all three transfers. Resident 57 had diagnoses including a displaced intertrochanteric fracture of the right femur, chronic kidney disease, and hypertension. After the family was notified of the resident's medical status, the resident was sent to the emergency room and the DON and ED were notified. The record contained transfer paperwork and a hearing request form, but the hearing request form lacked the resident's name, telephone number, and address, and the record lacked documentation that the resident's representative was notified in writing of the transfer/discharge appeal rights and bed hold policy. For Resident 22, the record showed multiple hospitalizations, but progress notes were missing for several of them, the transfer/discharge notices did not show that the resident or representative was notified of transfer/discharge rights, and for at least one hospitalization the record also lacked documentation that a report of the resident's condition was given to the receiving facility.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to administer PRN hydralazine according to physician orders for two residents with diagnoses that included hypertension and cognitive impairment. For one resident with Alzheimer's disease, essential hypertension, and atrial fibrillation, the record showed multiple blood pressure readings above the ordered systolic threshold of 165, including 170/83, 198/87, 181/77, 169/73, 170/72, 183/77, 170/88, 182/92, 175/83, and 181/86, yet hydralazine was not administered on those occasions. The resident's quarterly MDS indicated severely impaired cognition, and the care plan directed staff to administer medications as ordered and monitor blood pressure routinely. For the second resident, who had dementia, essential hypertension, and anxiety, the record showed several blood pressure readings above the ordered systolic threshold of 165, including 170/78, 172/84, 169/85, 168/93, 168/67, and 181/86, but hydralazine was not administered. The resident's quarterly MDS also indicated severely impaired cognition, and the care plan included administering hydralazine as ordered and monitoring blood pressure routinely. During interview, the DON stated the nurse practitioner had given instructions to recheck blood pressures an hour after medication administration and before giving hydralazine, and that blood pressure rechecks should be documented in progress notes; she was unsure whether those instructions were being followed or documented, and confirmed the medication was not administered per orders.
Failure to Follow Dietitian Recommendations for Resident With Significant Weight Loss
Penalty
Summary
Provide enough food/fluids to maintain a resident's health was not followed for a resident with Alzheimer’s disease, dementia, major depressive disorder, anxiety, psychosis, vitamin D deficiency, vomiting, and underweight status. The resident had significant weight loss, with weights documented as 94.8 pounds on 2/2/25 and 82.8 pounds on 8/1/25, a 12.66% loss over six months. The quarterly MDS indicated severe cognitive impairment, supervision/cueing needed with eating, significant weight loss, and a therapeutic diet. The care plan identified significant weight loss and included mirtazapine, assessment of causes of decreased intake, and interventions related to food preferences, depression/isolation, increased assistance, and dining atmosphere. A dietitian consult on 7/11/25 noted greater than 10% weight loss in six months and trending weight loss. The resident was receiving a regular diet with yogurt at breakfast, chocolate milk with meals, Boost with meals, and Boost three times daily, with variable acceptance of supplements. The dietitian recommended discontinuing Boost at meals to promote oral intake at meals, changing Boost Plus high protein to twice daily, and adding Boost Breeze daily. However, observations showed the resident was still given white milk on the tray and later received a Boost high protein supplement during the meal. An LPN stated chocolate milk was not on the dietary slip even though it was signed off on the MAR for each meal, and she had given chocolate Boost at meals and wondered if that counted as chocolate milk. The DON stated the dietitian’s recommendations were discussed with the NP, but documentation explaining why the recommendation to stop Boost at meals was not followed could not be provided.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure medications were stored in a secure manner when one medication cart was left unlocked and unattended. During an observation on 8/12/25 at 11:03 a.m., the 100-hallway medication cart was unattended and unlocked, and the hallway remained empty until 11:10 a.m. when two unidentified CNAs approached and entered a nearby resident room. At approximately 11:15 a.m., an LPN approached and locked the medication cart, stating she was the nurse responsible for it and had inadvertently left it unlocked; the keys were in her pocket. The cart contained medications for 19 residents. The DON later stated that all medication carts should be locked when not in use, and the facility’s Storing Drugs policy stated that drugs and biologicals must be stored in a safe, secure, and orderly manner and kept locked when a permitted person is not in the drug storage area.
Improper Bare-Hand Contact With Resident Food During Meal Service
Penalty
Summary
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. During an observation on 8/11/2025 at 12:06 p.m., a CNA offered to cut Resident 35's hamburger sandwich and used her left hand to place all five fingertips on the top bun, pushing it downward while using a knife in her right hand to cut the sandwich in half. During an interview later that day, the CNA stated she should not have touched the resident's food with her bare hands and that a fork and knife were to be used to cut a sandwich. The DON later stated staff were not to touch residents' food with bare hands and that staff had previously been educated on hand hygiene, food handling, and other food service specifics. A facility policy titled Glove Use & Meal Service stated employees may not touch ready-to-eat food with bare hands and that gloves must be worn.
Significant Medication Error Leads to Resident Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with a history of atrial fibrillation, heart disease, anemia, and a recent right femur fracture was admitted to the facility following hip surgery. The resident had physician orders for several medications, including buprenorphine-naloxone sublingual film for narcotic dependence and tramadol for pain. However, naloxone (Narcan) nasal spray, which was not ordered for the resident, was received from the pharmacy and placed in the medication cart. On the evening following admission, an LPN administered tramadol and then, in error, administered the naloxone nasal spray instead of the prescribed buprenorphine-naloxone sublingual film. The LPN noted the difference in medication forms but proceeded with the administration. Shortly after, the resident exhibited symptoms including feeling hot, trembling, and had a significant change in blood pressure. The resident was subsequently sent to the hospital for evaluation and treatment due to altered mental status and was admitted to the ICU with cardiogenic shock and acute cystitis. Interviews with facility staff and the pharmacist confirmed that naloxone was not intended to be administered and was not part of the facility's medication orders for the resident. The error was attributed to confusion between the naloxone nasal spray and the prescribed buprenorphine-naloxone film, as well as a failure to follow medication administration protocols, including verifying the correct medication and route. Facility policy required strict adherence to the six rights of medication administration and label checks, which were not followed in this instance.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to monitor vital signs according to physician orders before administering medications for three residents. Resident 24, diagnosed with dementia, myocardial infarction, atrial fibrillation, and hypertension, was prescribed metoprolol tartrate with specific parameters to hold the medication if the systolic blood pressure was below 120. Despite this, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold, as documented in the Medication Administration Reports (MAR) for June and August 2024. Resident 31, with diagnoses including hypertension, unsteadiness, atrial fibrillation, and tachycardia, was prescribed losartan with instructions to hold the medication if the systolic blood pressure was below 120. The MARs for June, July, and August 2024 showed that losartan was administered on several occasions when the resident's systolic blood pressure was below the required level. This indicates a failure to adhere to the physician's orders and monitor the resident's vital signs appropriately. Resident 35, diagnosed with dementia, heart failure, edema, hypertension, repeated falls, and rib fractures, was prescribed metoprolol succinate with a parameter to hold the medication if the heart rate was below 60. However, the MARs for July and August 2024 indicated that the medication was administered without recording the heart rate, and no vital signs were documented during this period. Interviews with LPNs revealed that the facility's electronic system requires vital signs to be entered before medication administration, yet this process was not followed, leading to the deficiency.
Inadequate Dining Experience Due to Improper Seating
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident, identified as Resident 35, who was observed dining in a wheelchair that was too low for the table height. This positioning required the resident to place her food bowl in her lap to eat, as her chin was at the level of the table. Observations over several days confirmed this issue, with the resident having to reach up to access her food, indicating a lack of appropriate seating arrangements. The resident's clinical record showed she had Alzheimer's disease, dementia, and other conditions, and required assistance with eating and transfers. Despite these needs, the care plan did not ensure a suitable dining environment. Interviews with staff, including the DON and CNAs, revealed awareness of the seating issue but no effective interventions had been implemented. The DON acknowledged the resident's low seating position but was uncertain about attempted solutions. A lower table was eventually brought in, but it was unclear if this was a consistent practice. The LPN mentioned an order for food to be served in bowls due to the seating issue, but this was not a satisfactory solution. The Administrator admitted there was no dining policy in place, indicating a lack of structured guidance for addressing such issues.
Failure to Update PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis. The resident, who had a history of vascular dementia, schizophrenia, major depressive disorder, generalized anxiety disorder, and psychotic disorder with delusions, exhibited significant behavioral symptoms such as delusions and physical aggression. Despite these changes in mental health status, the facility did not update the PASRR to reflect the resident's current diagnoses, which included new psychological conditions identified over several months. The deficiency was identified during a record review and interviews with facility staff. The Director of Nursing and the Social Services Director acknowledged that a new PASRR Level I screening was only submitted after the oversight was discovered. The facility lacked a specific policy for PASRR Level I, relying instead on provider guidelines. This oversight was contrary to the Indiana PASRR guidelines, which require a new Level I screening whenever there is a significant change in a resident's mental health status.
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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.
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Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit Health And Living | 6.2 mi | ★★★★★ | 9 | 0 |
| Bethany Pointe Health Campus | 7.3 mi | ★★★★★ | 4 | 1 |
| Northview Health And Living | 7.6 mi | ★★★★★ | 20 | 0 |
| Edgewater Woods | 7.8 mi | ★★★★★ | 6 | 0 |
| Beaumont Rehabilitation And Healthcare Center | 8.1 mi | ★★★★★ | 28 | 0 |
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