Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
126% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Apr 24, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00457758 and IN00457639.
Findings
No deficiencies related to the allegations in complaints IN00457758 and IN00457639 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Investigation of Complaints IN00457758 and IN00457639 found no deficiencies related to the allegations.
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 11
Medicaid Census: 38
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Feb 18, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452573.
Findings
No deficiencies related to the allegations in Complaint IN00452573 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452573 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 8
Medicaid census: 33
Other payor census: 9
Inspection Report
Re-Inspection
Census: 43
Capacity: 70
Deficiencies: 0
Oct 21, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/16/2024.
Findings
At this PSR survey, Alexandria Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers, including 42 CFR 483.73 and 42 CFR Subpart 483.90(a). The facility has two buildings, both fully sprinklered except for a detached garage used for storage.
Report Facts
Certified beds: 70
Census: 43
Generator capacity: 50
Inspection Report
Life Safety
Census: 43
Capacity: 70
Deficiencies: 11
Sep 16, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, with multiple deficiencies related to fire safety, emergency preparedness, and building construction in both buildings. Deficiencies included unsealed penetrations in smoke barriers, dead-end corridors exceeding allowed length, lack of emergency lighting at the generator, unsecured oxygen storage, and improper storage of liquid oxygen in resident rooms.
Severity Breakdown
SS=A: 2
SS=C: 1
SS=D: 1
SS=E: 3
SS=F: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan failed to include a documented, facility-based risk assessment utilizing an all-hazards approach. | SS=C |
| Dead-end corridor exceeded 30 feet in length without proper exit signage. | SS=E |
| Resident room corridor door did not latch properly to resist passage of smoke. | SS=D |
| Penetrations through smoke barrier walls were not sealed to maintain smoke resistance in Building 01. | SS=F |
| Emergency task generator lacked a battery backup light. | SS=F |
| Outside oxygen storage area was not locked and lacked required precautionary signage. | SS=E |
| Liquid oxygen cylinders stored in resident rooms were not separated by proper fire barriers and doors were not self-closing or automatic closing in Building 01. | SS=A |
| Building 02 failed to maintain one-hour fire resistance ceiling barrier between attic and living areas. | SS=E |
| Penetrations through smoke barrier walls were not sealed to maintain smoke resistance in Building 02. | SS=F |
| Emergency task generator in Building 02 lacked a battery backup light. | SS=F |
| Liquid oxygen cylinders stored in resident room in Building 02 were not separated by proper fire barriers and doors were not self-closing or automatic closing. | SS=A |
Report Facts
Certified beds: 70
Census: 43
Dead-end corridor length: 35
Resident rooms with liquid oxygen: 5
Resident rooms with liquid oxygen: 1
Resident rooms with corridor door issues: 2
Resident rooms with oxygen storage issues: 10
Resident rooms with liquid oxygen storage deficiency: 6
Residents potentially affected by dead-end corridor: 20
Residents potentially affected by fire resistance ceiling barrier deficiency: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Burke | Administrator | Named in relation to findings and exit conference |
| Regional Maintenance Director | Involved in record review, interviews, and exit conference | |
| Facility Maintenance Director | Involved in observations, interviews, and exit conference |
Inspection Report
Renewal
Census: 44
Capacity: 44
Deficiencies: 3
Aug 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 25 through August 30, 2024.
Findings
The facility was found deficient in providing a dignified dining experience for one resident, failed to submit an updated PASRR for a resident with new mental health diagnoses, and did not monitor vital signs per physician orders prior to medication administration for three residents. Plans of correction and staff education were implemented to address these issues.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide a dignified dining experience for 1 of 14 residents observed during dining on the secured unit (Resident 35). | SS=D |
| Failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis (Resident 12). | SS=D |
| Failed to monitor vital signs per physician orders prior to giving medications for 3 of 3 residents reviewed (Residents 24, 31, and 35). | SS=E |
Report Facts
Census: 44
Total Capacity: 44
Survey Dates: 6
Residents with medication hold parameters reviewed: 3
Residents observed during dining: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Indicated resident had an order for food to be placed in bowls and described medication administration process |
| CNA 6 | Certified Nursing Assistant | Assisted Resident 35 in wheelchair to dining table |
| CNA 7 | Certified Nursing Assistant | Provided information about Resident 35's dining seating |
| LPN 8 | Licensed Practical Nurse | Described medication hold parameters and administration process |
| LPN 9 | Licensed Practical Nurse | Described taking vitals and holding medications when parameters not met |
| Director of Nursing | Director of Nursing | Provided information on dining seating concerns and medication administration in-service |
| Administrator | Facility Administrator | Indicated facility did not have a policy on dining |
| Social Services Director | Social Services Director | Indicated submission of updated PASRR and lack of PASRR Level I policy |
| Corporate Social Services Consultant | Consultant | Indicated facility followed PASRR provider guidelines |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 30, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Alexandria Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 44
Capacity: 70
Deficiencies: 0
Aug 23, 2024
Visit Reason
A Pre-Occupancy Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Alexandria Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for one detached garage and has a fire alarm system with smoke detection throughout resident areas.
Report Facts
Facility capacity: 70
Census: 44
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
Dec 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422387.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00422387 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 4
Medicaid census: 23
Other payor census: 7
Inspection Report
Plan of Correction
Census: 34
Capacity: 70
Deficiencies: 0
Dec 1, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/24/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Alexandria Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and smoke detectors in all resident sleeping rooms. All resident access areas and facility service areas were sprinklered except for one detached garage.
Report Facts
Facility capacity: 70
Census: 34
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 31, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Alexandria Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 33
Capacity: 70
Deficiencies: 5
Oct 24, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements. Deficiencies included a missing fire alarm pull station, sprinkler heads covered with insulation, a corridor door failing to close and latch properly, an electrical splice not enclosed in a junction box, and improper mechanical ventilation in the oxygen storage/transfer room.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 5 manual fire alarm boxes (pull stations) were installed and functioning properly; missing pull station near employee break room. | SS=E |
| Failed to ensure attic sprinkler heads were not loaded or covered with foreign material; sprinkler heads covered with insulation in attic above employee break room. | SS=E |
| Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching; double barrier doors near Resident Room 102 failed to close and latch positively. | SS=E |
| Failed to ensure 1 of 1 electrical splices were made in a junction box; electrical splice in attic above break room not contained in junction box. | SS=E |
| Failed to ensure oxygen storage room where oxygen transferring takes place was provided with properly working mechanical ventilation; vents not working in oxygen storage/transfer room. | SS=E |
Report Facts
Certified beds: 70
Census: 33
Residents potentially affected by missing pull station: 12
Residents potentially affected by sprinkler head issue: 20
Residents potentially affected by door issue: 20
Residents potentially affected by electrical splice issue: 20
Residents potentially affected by oxygen room ventilation issue: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged findings during observations and exit conference | |
| Maintenance Director | Acknowledged findings during observations and exit conference; responsible for corrective actions and re-education |
Inspection Report
Renewal
Census: 38
Capacity: 38
Deficiencies: 3
Oct 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on September 27, 28, 29, and October 2 and 3, 2023.
Findings
The facility was found deficient in developing and implementing individualized interventions to reduce physical aggression toward residents with dementia, securing medications after administration, and ensuring residents were up to date with pneumococcal vaccinations. The facility submitted plans of correction addressing these issues.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop and implement individualized interventions to reduce physical aggression toward a resident with dementia. | SS=D |
| Failed to ensure medication was secured after administration for one resident. | SS=D |
| Failed to ensure one resident received pneumococcal vaccination to remain up to date. | SS=D |
Report Facts
Census: 38
Total Capacity: 38
Survey Dates: 5
Inspection Report
Follow-Up
Census: 38
Capacity: 70
Deficiencies: 0
Aug 28, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Pre-Occupancy Survey conducted on 07/21/23 was performed to verify compliance with Life Safety Code requirements.
Findings
At this PSR Pre-Occupancy Life Safety Code survey, Alexandria Care Center was found in compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered except for one detached garage and has a fire alarm system with smoke detection in required areas.
Report Facts
Facility capacity: 70
Census: 38
Inspection Report
Original Licensing
Census: 45
Capacity: 70
Deficiencies: 5
Jul 21, 2023
Visit Reason
A Pre-Occupancy Emergency Preparedness and Life Safety Code Survey was conducted to assess compliance with Medicare and Medicaid participation requirements and Life Safety Code standards for the new facility addition and renovations.
Findings
The facility was found in compliance with Emergency Preparedness requirements but had multiple Life Safety Code deficiencies related to delayed egress door signage, emergency lighting, interior wall finishes, sprinkler system maintenance, ceiling construction, and electrical outlet protection in the new 400 hall area.
Severity Breakdown
SS=E: 3
SS=F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure means of egress through 1 of over 8 delayed egress locks was readily accessible and lacked proper signage stating 'PUSH UNTIL ALARM SOUNDS. DOOR CAN BE OPENED IN 15 SECONDS'. | SS=E |
| Failed to provide exterior emergency lighting for all exits, specifically missing exit lights outside the 400 hall exit. | SS=E |
| Failed to ensure materials used as interior finish on 1 of 1 Service Hallway had a flame spread rating of Class A or B as required. | SS=F |
| Failed to maintain ceiling construction on the new 400 hall; missing ceiling tiles and gaps around wires penetrating suspended ceiling tiles. | SS=F |
| Failed to ensure electrical outlets in the new 400 hall were protected; missing outlet/switch covers and exposed wiring in ceiling light box. | SS=E |
Report Facts
Certified beds: 70
Census: 45
Delayed egress locks: 8
Residents potentially affected: 20
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Mar 9, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00403656 and IN00402682.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00403656 and IN00402682 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 40
Medicare Census: 3
Medicaid Census: 31
Other Payor Census: 6
Inspection Report
Life Safety
Census: 39
Capacity: 70
Deficiencies: 0
Nov 15, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/21/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Alexandria Care Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered except for one detached garage.
Report Facts
Facility capacity: 70
Census: 39
Inspection Report
Life Safety
Census: 41
Capacity: 70
Deficiencies: 3
Sep 21, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to document annual 90-minute testing for all battery backup lights, failure to provide exterior emergency lighting connected to the generator at all exits, and insufficient space in the oxygen transfilling room to safely perform the procedure with the door closed.
Severity Breakdown
SS=F: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to document annual 90-minute testing for all battery backup lights as required by Life Safety Code 7.9. | SS=F |
| Failed to provide exterior emergency lighting connected to the generator at all facility exits as required by Life Safety Code 7.9.1.1. | SS=F |
| Oxygen transfilling room did not have sufficient space to accomplish the procedure with the door closed, violating NFPA 99 requirements. | SS=E |
Report Facts
Certified beds: 70
Census: 41
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Maintenance Professional | Acknowledged findings related to emergency lighting and oxygen transfilling room deficiencies | |
| Administrator | Participated in interviews and exit conference regarding deficiencies | |
| Administrator in Training | Participated in interviews and exit conference regarding deficiencies | |
| Maintenance Director | Re-educated and responsible for implementing monitoring tools for corrective actions | |
| Respiratory Therapist | Demonstrated oxygen transfilling procedure and confirmed practice |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 7, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00388182 completed on August 19, 2022.
Findings
Alexandria Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00388182 completed with compliance found.
Inspection Report
Re-Inspection
Census: 43
Capacity: 43
Deficiencies: 0
Sep 6, 2022
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 12, 2022.
Findings
Alexandria Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 43
Total Capacity: 43
Medicare Census: 4
Medicaid Census: 34
Other Census: 5
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 1
Aug 19, 2022
Visit Reason
This visit was for the investigation of Complaint IN00388182, which was substantiated with federal/state deficiencies cited.
Findings
The facility failed to prevent physical abuse of a cognitively impaired resident (Resident B), resulting in bruising and skin tears. Multiple staff interviews and record reviews confirmed the abuse incident involving CNA 11.
Complaint Details
Complaint IN00388182 was substantiated. The abuse involved Resident B, who suffered bruising and skin tears due to physical abuse by CNA 11. Multiple staff interviews corroborated the incident. CNA 11 no longer works at the facility.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent physical abuse of a cognitively impaired resident resulting in bruising and skin tears. | SS=D |
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 5
Medicaid Census: 32
Other Payor Census: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 11 | Certified Nursing Assistant | Named in physical abuse finding; no longer employed at the facility |
| CNA 8 | Certified Nursing Assistant | Reported abuse concern to Administrator |
| CNA 12 | Certified Nursing Assistant | Provided information about Resident B's behaviors |
| LPN 17 | Licensed Practical Nurse | Interviewed regarding incident and resident condition |
| CNA 19 | Certified Nursing Assistant | Reported CNA 11 told nurse about resident's skin tears |
Inspection Report
Annual Inspection
Census: 43
Capacity: 43
Deficiencies: 7
Aug 12, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 8 to 12, 2022.
Findings
The facility was cited for multiple deficiencies including failure to ensure residents had access to call lights, incomplete advance directive documentation, failure to complete PASRR assessments for residents with mental illness, lack of individualized non-pharmacological interventions for dementia behaviors, failure to provide ordered medications timely, improper medication storage, and failure to complete ordered laboratory tests.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Residents 189, 2, and 35 did not have call lights within reach. | SS=D |
| Resident 23's advance directive was not signed by the resident or representative. | SS=D |
| Facility failed to complete PASRR for residents newly diagnosed with mental illness (Residents 19, 5, 31, 33, and 40). | SS=E |
| Facility failed to identify and implement individualized, non-pharmacological interventions for residents with dementia behaviors (Residents 31, 33, and 5). | SS=D |
| Facility failed to provide ordered medications for Resident 40 due to lack of supply. | SS=D |
| Medication carts were found unlocked and unattended with medications and treatments not properly secured. | SS=D |
| Facility failed to ensure laboratory orders were collected and completed for Residents 35 and 5. | SS=D |
Report Facts
Survey dates: 5
Census: 43
Total capacity: 43
Residents reviewed for PASRR: 7
Residents with PASRR deficiencies: 5
Residents reviewed for dementia care: 4
Residents reviewed for medication use: 7
Residents with medication deficiencies: 1
Residents reviewed for lab orders: 5
Residents with lab order deficiencies: 2
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