Alexandria Care Center: Antibiotic Oversight Gap - CA]
The facility's own policy, titled "Antibiotic Stewardship — Review and Surveillance of Antibiotic Use and Outcomes," was dated September 2023 and last reviewed in January 2025. It was specific. Every resident treated for a clinical infection with antibiotics would be reviewed by the infection preventionist. The infection preventionist would identify situations where antibiotic use did not match appropriate prescribing standards. At the end of each review, the prescribing provider would be notified of the findings. Every antibiotic regimen would be logged on a facility-approved antibiotic surveillance tracking form.
The facility had a second policy to back it up. Its "Infection Prevention and Control Program," also last reviewed in January 2025, stated that culture reports, sensitivity data, and antibiotic usage reviews were all part of the facility's surveillance activities, and that practitioners would receive feedback on those reviews.
Two policies. Both current. Both detailed. Both describing a functioning system in which someone was watching how antibiotics were being prescribed, catching problems, and telling doctors about them.
Inspectors cited the facility under federal deficiency tag F0881, which covers antibiotic stewardship programs. The citation was rated as minimal harm or potential for actual harm, and inspectors noted that few residents were affected. The finding was part of a complaint inspection, meaning someone had raised a concern that prompted the visit.
What the inspection report does not show is evidence that the tracking log existed in practice, that the infection preventionist was conducting the required reviews, or that providers were receiving the feedback the policy promised them.
That gap matters in ways that go beyond paperwork. Antibiotic stewardship programs exist because the overuse and misuse of antibiotics is one of the most serious problems in long-term care. Residents in nursing homes are prescribed antibiotics at high rates, and a significant portion of those prescriptions are later found to be unnecessary or inappropriate. When antibiotics are given without a confirmed infection, or when the wrong antibiotic is chosen for the organism causing an infection, residents can be harmed. They can develop side effects. They can acquire infections caused by drug-resistant organisms. The broader facility population can be exposed to pathogens that become harder to treat over time.
The review process Alexandria Care Center described in its own policies is the mechanism designed to catch those problems before they compound. The infection preventionist reviews the case. The infection preventionist checks whether the antibiotic chosen matches the culture and sensitivity data. The infection preventionist tells the doctor if something looks off. The doctor, now informed, can adjust the prescription or reconsider the course of treatment entirely.
If that loop is not running, the errors it is designed to catch go uncaught. A resident receives an antibiotic that does not match their infection. Nobody flags it. The provider is never notified. The tracking log stays empty or incomplete. The data that was supposed to guide facility-wide improvement is never collected, so the improvement never happens.
Alexandria Care Center's policies acknowledged all of this. The language in both documents is not vague or aspirational. It names specific steps, assigns them to specific roles, and describes specific outputs: a log, a notification, a review. The facility reviewed those policies as recently as January 2025, eleven months before inspectors arrived.
The deficiency was cited at the lower end of the harm scale, and the inspection report does not identify a specific resident who was harmed by an incorrect antibiotic or a missed review. But the structure of an antibiotic stewardship failure is that the harm is often invisible at first. A resident who receives the wrong antibiotic and recovers anyway does not appear in an incident report. A drug-resistant infection that takes hold weeks later may not be traced back to the prescription that preceded it.
What inspectors documented at Alexandria Care Center was a facility that had told itself, in writing, exactly what it needed to do to keep residents safe from antibiotic misuse, and then did not do it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alexandria Care Center from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 22, 2026 · Our methodology
ALEXANDRIA CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on December 30, 2025.
Every resident treated for a clinical infection with antibiotics would be reviewed by the infection preventionist.
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.