Alexandria Care Center: Insulin Safety Failures - CA
At Alexandria Care Center, staff administered multiple insulin shots to the same locations on residents' arms and abdomens over weeks, creating risks for lipodystrophy — painful lumps and thickened skin that can interfere with insulin absorption.
The violations affected at least three diabetic residents who required daily insulin injections to manage their blood sugar levels.
Resident 51's Repeated Abdomen Injections
Resident 51, readmitted in June 2024 with type 2 diabetes and chronic lung disease, received long-acting insulin injections in the same abdominal areas repeatedly. Medication records showed nurses administered shots in the left upper quadrant of the abdomen on December 5, 6, 12, 13, 26, and 27, then again on January 16, 17, and 18.
The resident, who lacked decision-making capacity and required total assistance with daily activities, also received short-acting insulin shots in the same left arm on consecutive days in December.
Licensed Vocational Nurse 2 acknowledged during interviews that insulin sites should be rotated according to manufacturer guidelines and nursing standards. "Resident 51's insulin administration sites should have been rotated per manufacturer's guidelines and standards of practice to prevent pain, redness, irritation, and bumps or lumps on the resident's skin," LVN 2 told inspectors.
Resident 137's Concentrated Injection Pattern
The pattern was even more problematic for Resident 137, who has congestive heart failure and severe cognitive impairment requiring total assistance with all daily activities.
Nurses gave this resident short-acting insulin shots in the right arm four times within two days in December — at 9:02 p.m. on December 2, 6:06 a.m. on December 3, then twice more on December 11 and 12 in the same right arm.
For long-acting insulin, staff concentrated injections in the same abdominal quadrants repeatedly. The right lower quadrant received shots on December 18 and 19, while the left upper quadrant was used on December 18 and 19.
The facility's Director of Nursing confirmed the violations during interviews. "The administration sites of insulin should be rotated per as indicated in the manufacturer's guideline and according to standards of practice to prevent complications such as bruising, and lipodystrophy," the DON stated.
Third Resident's Left Arm Pattern
Resident 129 experienced similar concentrated injections, with nurses administering regular insulin in the left arm on January 12 at three different times — 11:30 a.m., 4:30 p.m., and 9 p.m. Four days later, staff again used the left arm for shots at 11:30 a.m. and 9 p.m.
The DON called this pattern "a significant medication error" that could cause lipodystrophy at repeated administration sites.
Manufacturer Guidelines Ignored
The facility's own manufacturer guidelines for Lantus insulin, revised in June 2023, specifically instruct staff to "rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis."
The guidelines warn against injecting "into the areas of lipodystrophy or localized cutaneous amyloidosis" and specify not to "use the exact same spot for each injection."
Similar warnings appear in the facility's insulin lispro guidelines, which state: "Do not inject where the skin has pits, is thickened, or has lumps. Do not inject where the skin is tender, bruised, scaly or hard, or into scars or damaged skin."
Physical Therapy Refusals Unaddressed
Inspectors also found the facility failed to properly address a rehabilitation patient's repeated refusals to participate in physical therapy.
Resident 147, admitted in November 2024 after a hip fracture with "good rehab potential," refused therapy sessions on December 12, 13, 16, 17, and January 10. Physical Therapist 1 documented the refusals as "refused treatment even with maximum encouragement" and "refused treatment multiple attempts and max encouragement."
During an observation on January 30, the resident again refused to continue therapy after briefly sitting on the side of the bed, stating she wanted to lie back down.
The resident's son, Responsible Party 1, told inspectors he couldn't visit daily to encourage participation. "The goal for Resident 147 is to go home and doing the exercise will help her get strong enough to go home with him," RP 1 explained. "Resident 147 does not even want to open her eyes, her mind is okay, but she just chose not to do the rehab exercises."
Despite the repeated refusals, facility staff failed to hold required interdisciplinary team meetings with the family or notify the resident's physician about the therapy refusals.
MDS Nurse 1 acknowledged the oversight: "They should have developed the care plan when the resident had multiple refusals. This was not done and should have been documented in the IDT notes to reflect that it was discussed and addressed."
Equipment Safety Hazards
Inspectors documented multiple fall hazards affecting residents with floor mats designed to prevent injury from falls.
At three residents' bedsides, staff had placed overbed tables directly on top of protective floor mats for extended periods. The table wheels created indentations in the mats, compromising their protective function.
Licensed Vocational Nurse 3 acknowledged the safety risk when inspectors pointed out the indented mat in Resident 94's room. "Resident 94's overbed table can be unstable and fall on the resident or Resident 94 can hit the table when he tries to get out of bed unassisted," LVN 3 stated.
The facility's manufacturer guidelines for floor mats specifically warn to "avoid placing furniture or equipment on the mat as this may cause permanent indentations to occur."
Bed Left in Dangerous Position
Certified Nursing Assistant 3 left Resident 129's bed in the elevated position while the resident was unattended, despite the resident being classified as a fall risk with floor mats on both sides of the bed.
When inspectors observed the situation, CNA 3 initially didn't realize the safety violation. After being informed the resident was a fall risk, CNA 3 acknowledged: "She should not have left the resident's bed in the high position because the resident was considered at risk for falls."
The Director of Staff Development confirmed the danger: "There was a higher risk for injuries, like fractures, when a resident falls from the bed in the high position."
Medical Equipment Mismanagement
A resident using a low air loss mattress to prevent pressure sores had no physician's order for the specialized equipment, and staff were manipulating the settings incorrectly.
Certified Nursing Assistant 4 told inspectors he routinely set the mattress weight limit higher than the resident's actual weight to prevent alarms. "The resident's LALM will alarm every 15 minutes so he sets the LALM settings beyond the resident's weight," according to inspection notes.
The practice had continued for approximately three months without proper medical oversight or care planning for the pressure-prevention device.
The violations occurred during a January 31, 2025 inspection at the 1515 N Alexandria Avenue facility, which has faced ongoing scrutiny over resident care and safety practices.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALEXANDRIA CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on January 31, 2025.
The violations affected at least three diabetic residents who required daily insulin injections to manage their blood sugar levels.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.