LOS ANGELES, CA - State inspectors found significant medication administration errors and food safety violations at Alexandria Care Center during a January 2025 inspection, documenting problems that placed residents at risk for health complications.
Critical Medication Administration Errors
The inspection revealed systematic failures in insulin administration practices affecting multiple diabetic residents. Inspectors documented that nursing staff repeatedly failed to rotate injection sites when administering insulin to at least three residents, despite clear facility policies and manufacturer guidelines requiring site rotation.
For Resident 51, medication records showed insulin injections were administered to the same body areas repeatedly over several weeks. Between December 2024 and January 2025, the resident received multiple insulin injections in the left upper quadrant of the abdomen on consecutive days, with some injection sites used as many as four times within a short period.
Similar patterns were documented for Resident 137, where insulin was administered to the same arm location on multiple consecutive days. Licensed Vocational Nurse 2 confirmed during the inspection that "insulin administration sites were not rotated" and acknowledged this constituted "a medication error by not following the manufacturer's guideline and standards of practice."
Medical Consequences of Improper Injection Practices
Failure to rotate insulin injection sites can lead to serious medical complications. When insulin is repeatedly injected into the same location, it can cause lipodystrophy - a condition where fat tissue becomes lumpy or develops pits. This tissue damage makes insulin absorption unpredictable, potentially leading to dangerous blood sugar fluctuations.
The condition can also cause localized cutaneous amyloidosis, where protein deposits form lumps under the skin. These complications not only affect the medication's effectiveness but can also cause pain, bruising, and permanent skin damage for residents who require daily insulin injections.
Medical protocols require rotating injection sites within the same general body area (such as different areas of the abdomen or alternating arms) to prevent these complications. The facility's own policy clearly stated that "injection sites should be rotated, preferably within the same general area."
Expired and Improperly Stored Medications
Inspectors found multiple instances of expired or improperly stored medications that could have resulted in ineffective treatment or health complications. In one medication cart, seven inhalation solutions for treating shortness of breath had been stored outside their required foil packaging for over two weeks, rendering them expired and potentially ineffective.
An insulin vial was found stored at room temperature without the required dating to track when it would expire. This creates a serious risk because expired insulin loses its potency and cannot effectively control blood sugar levels, potentially leading to diabetic coma or other life-threatening complications.
Additionally, an eye drop medication was found that had expired four days prior to the inspection. Using expired eye medications can be ineffective for treating glaucoma and other eye conditions, and may increase the risk of eye infections due to loss of sterility.
Food Service Failures Create Nutritional Risks
The inspection documented multiple food service violations that compromised resident nutrition and food safety. Kitchen staff consistently failed to provide proper portion sizes to residents requiring pureed or soft mechanical diets, using improperly filled measuring scoops that resulted in smaller servings.
Temperature control problems were also identified. Cold foods like sliced pears were served at 68°F instead of the required temperature below 41°F. Coleslaw sat unrefrigerated on the serving line for over 25 minutes, reaching 75°F. These temperature violations create risks for foodborne illness in a vulnerable population.
Menu substitutions were made without proper planning when kitchen staff ran out of rice and substituted mashed potatoes with tacos - a combination that dietary staff acknowledged would be unappetizing and could lead to reduced food intake.
Impact on Resident Health and Nutrition
Improper portion sizes and unappetizing food combinations can lead to decreased caloric intake and unintended weight loss in elderly residents who may already struggle with maintaining adequate nutrition. For residents with diabetes and other chronic conditions, consistent carbohydrate intake is essential for medication effectiveness and blood sugar control.
Temperature violations in food service create risks for foodborne illness, which can be particularly dangerous for elderly residents with compromised immune systems. The facility's own policies required hot foods to be maintained above 135°F and cold foods below 41°F to prevent bacterial growth.
Kitchen Sanitation and Safety Violations
Multiple kitchen sanitation issues were documented that could lead to cross-contamination and foodborne illness. These included dirt buildup on walk-in refrigerator and freezer floors, dust accumulation on ventilation systems, and improper food handling practices.
Staff were observed washing cleaning cloths in the same sink area where raw chicken was thawing, creating a risk for bacterial contamination. Cracked and chipped serving trays were still in use, providing surfaces where bacteria could grow and potentially contaminate food.
Documentation Failures in Medical Records
The inspection found gaps in medication administration documentation for two residents receiving insulin. Missing documentation entries make it impossible to track whether critical medications were actually administered, creating risks for both under-medication and over-medication.
Additional Issues Identified
The inspection also documented problems with infection control practices, including unlabeled urinals that could be shared between residents and improperly stored respiratory equipment. Waste management violations included uncovered dumpsters and unlined trash receptacles that could attract pests and spread contamination.
The facility's policies clearly outlined proper procedures for all these areas, but staff implementation was inconsistent. The Director of Nursing acknowledged during interviews that several violations represented failures to follow established protocols and manufacturer guidelines.
These violations collectively created an environment where residents faced increased risks for medication errors, foodborne illness, and inadequate nutrition - serious concerns for a facility caring for medically vulnerable elderly residents requiring specialized care and close monitoring of their health conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alexandria Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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