Cycle 1
Health 2025-08-15 · Fire 2025-08-15
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Alexandria, IN
Alexandria Care Center
3-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1912 S Park Ave, Alexandria, IN
(765) 724-4478
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
54
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,630
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 5.53% · Performance 7.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.94
Baseline 50.94% · Performance 55.77% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Adjusted total nurse staffing
1.47
Baseline 3.62 hours · Performance 3.50 hours · Measure score 1.47 · Achievement 1.47 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 6.71% |
| Discharge to community | 58.37% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 65.38% · Lower 95% interval 45.02% |
| Medicare spending per beneficiary | 1.49 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 16 · Denominator 30 |
| Discharge mobility score | 56.67% |
50.94%
5.7 pts better
|
Numerator 17 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 5.13% |
2.29%
2.8 pts worse
|
Numerator 2 · Denominator 39 · Adjusted rate 5.3% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 51 |
| Staff flu vaccination coverage | 13.13% |
42%
28.9 pts worse
|
Numerator 13 · Denominator 99 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 6 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.5
1.9 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
95.4%
2.3 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.8% |
3.8%
6 pts worse
|
3.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 14.6% · Q3 7.8% · Q4 6.2% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.7% |
24.6%
4.1 pts worse
|
11.4%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 28.6% · Q3 21.7% · Q4 28.6% · 4Q avg 28.7% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.6%
3.1 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 13.5% · Q3 11.6% · Q4 7.1% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.2% |
23.5%
16.7 pts worse
|
19.6%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 40.5% · Q3 40.9% · Q4 32.6% · 4Q avg 40.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
14.8%
5.9 pts worse
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 17.9% · Q3 25.0% · Q4 20.6% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 42.1% |
13.3%
28.8 pts worse
|
16.3%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q3 40.2% · Q4 29.0% · 4Q avg 42.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 41.8% |
11.7%
30.1 pts worse
|
14.9%
26.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.3% · Q2 48.6% · Q3 29.3% · Q4 39.0% · 4Q avg 41.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.3% |
24.2%
15.1 pts worse
|
19.8%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 44.3% · Q3 59.0% · Q4 36.6% · 4Q avg 39.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.1%
0.3 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.5% · Q3 7.2% · Q4 2.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
81.6%
16.1 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.0% · Q3 97.8% · Q4 98.0% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
10.5%
13.6 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 23.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.3%
0.7 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
22.4%
6.1 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 26.5% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-30 · Fire 2024-08-30
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-10-03 · Fire 2023-10-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-09-27
F · Potential for more than minimal harm
2024-08-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-08
F · Potential for more than minimal harm
2024-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-08-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-08-30
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-08-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-08
C · Minimal harm
2024-08-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-08
E · Potential for more than minimal harm
2023-10-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-10-03
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-11-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-08
E · Potential for more than minimal harm
2024-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-08-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-03
D · Potential for more than minimal harm
2023-10-03
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-10-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-10-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-06
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bayston, Brett
Corporate Director · Individual
Bohannon, Jennifer
Operational/Managerial Control · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hafidh, Saad
Operational/Managerial Control · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Magnolia Health Management I LLC
Operational/Managerial Control · Organization
Reagan, Julie
Corporate Director · Individual
Reed, Stuart
Operational/Managerial Control · Individual
Sellers, Daniel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Summit Health And Living
Summitville, IN
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Bethany Pointe Health Campus
Anderson, IN
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Northview Health And Living
Anderson, IN
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
Jump out