The facility administered azithromycin to Resident 1 starting November 29, 2025, to treat legionnaires disease. But nurses didn't create the care plan until December 3 — four days after treatment began.
The medication administration record showed Resident 1 received azithromycin on November 30, December 1, and December 2. During that period, nursing staff had no written guidance on what interventions to perform to achieve the resident's treatment goals.
RN 1 acknowledged the delay during a December 24 interview with inspectors. The nurse stated the care plan for azithromycin "was not developed until 12/3/2025" and explained that care plans "inform the nurses on what intervention to perform to achieve resident's goals."
The Director of Nursing admitted the facility was late in developing both the antibiotic care plan and the legionnaires disease care plan. Both should have been created on November 29, the DON told inspectors.
"Care plan guides the nurses on what to do to address Resident 1's problems," the DON stated. "Not timely development of a care plan could possibly result in nurses not performing the interventions to provide care to Resident 1."
The facility's Infection Preventionist echoed those concerns. During her December 24 interview, the IP explained that care plans "help nurses care for the residents" and that delays in developing them "could potentially delay Resident 1's care."
The violation highlights gaps in the facility's care planning process for residents receiving antibiotic treatment. Federal regulations require nursing homes to develop individualized comprehensive care plans that include measurable objectives and timetables for each resident's medical needs.
Alexandria Care Center's own policy, last reviewed in January 2025, states that comprehensive care plans must incorporate identified problem areas and reflect treatment goals with measurable outcomes. The policy requires assessments to be ongoing, with care plans reviewed and revised as resident conditions change.
The facility's policy also mandates that care plans reflect "currently recognized professional standards of practice for problem areas and conditions" and include "services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being."
Despite these requirements, nursing staff proceeded with antibiotic treatment without the written framework designed to ensure proper care delivery.
The four-day delay occurred during critical early treatment for legionnaires disease, a serious form of pneumonia that requires careful monitoring and intervention. Without care plans, nurses lacked specific guidance on monitoring protocols, potential side effects, or necessary interventions during the antibiotic course.
Azithromycin, the antibiotic administered to Resident 1, requires specific nursing interventions and monitoring that would typically be outlined in a care plan. These might include watching for adverse reactions, monitoring vital signs, ensuring proper medication timing, and coordinating with physicians on treatment progress.
The inspection found that nursing staff continued administering the medication through December 2 while operating without the facility's own required care planning framework.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the facility's leadership acknowledged the systemic nature of the problem and its potential impact on patient care quality.
The DON's admission that late care plan development "could possibly result in nurses not performing the interventions" suggests the delay created real risks for Resident 1's treatment outcomes.
The Infection Preventionist's concern that delayed care plans "could potentially delay Resident 1's care" indicates the facility recognizes how procedural failures can cascade into direct patient impact.
Alexandria Care Center operates at 1515 N Alexandria Ave in Los Angeles. The facility's care planning failures occurred despite having written policies that clearly outline requirements for timely development of comprehensive care plans.
The inspection, completed December 30, 2025, found the facility violated federal requirements for comprehensive care plans that must be developed to address residents' medical conditions and treatment needs.
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.