Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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 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.
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 | — | 3 | 0 |
| Bethany Pointe Health Campus | 7.3 mi | — | 4 | 1 |
| Northview Health And Living | 7.6 mi | — | 19 | 0 |
| Edgewater Woods | 7.8 mi | — | 5 | 0 |
| Beaumont Rehabilitation And Healthcare Center | 8.1 mi | — | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.