Alexandria Care Center: Medical Record Failures - CA
Inspectors visited the 1515 N. Alexandria Ave. facility on December 30, 2025, following a complaint. What they found was a discrepancy between what the medical record said and what the director of nursing acknowledged should have been documented, a gap that the nursing director herself described as a patient safety concern.
The resident at the center of the complaint, identified in inspection records only as Resident 1, had experienced low oxygen saturation. That condition, when left unaddressed or improperly treated, can cause organ damage, confusion, and in severe cases, death. What gets documented in a medical record matters because it tells every nurse and doctor who walks through the door what was done, what worked, and what to do next.
The record said a face mask with 15 liters of oxygen had been used.
The director of nursing told inspectors that was a problem. She said that delivering oxygen by face mask at 15 liters would not be effective and could cause the resident's saturation to remain low. She said accurate documentation was essential to show what intervention was actually provided when a resident was in that condition.
She did not dispute that the documentation was wrong. She explained why it mattered.
A standard non-rebreather face mask, used in emergencies, typically delivers oxygen at flow rates between 10 and 15 liters per minute and is designed for acute respiratory distress. Documenting that a resident received that treatment, when the nursing director indicated it would not have been effective and was not the appropriate recorded intervention, leaves a gap in the clinical picture that any subsequent caregiver would be working from blind.
The facility's own nursing documentation policy, reviewed by inspectors during the visit, laid out the standard plainly. Documentation should be concise, clear, pertinent, and accurate. It should reflect the resident's status, the nursing assessment, the interventions provided, the expected outcomes, and the resident's actual response to care. The policy existed. The documentation did not meet it.
Inspectors cited the deficiency under F0842, which covers the accuracy and completeness of medical records. The level of harm was classified as minimal harm or potential for actual harm, meaning inspectors found no documented evidence that Resident 1 suffered a measurable injury as a direct result of the record error. A small number of residents were identified as affected.
That classification does not mean the gap was trivial. A medical record that inaccurately reflects what oxygen treatment a resident in respiratory distress received is a record that the next nurse, the on-call physician, or an emergency responder cannot rely on. If Resident 1's oxygen levels dropped again, whoever responded would be working from documentation that the facility's own nursing director said described an ineffective intervention.
Alexandria Care Center is a licensed skilled nursing facility in the Los Feliz neighborhood of Los Angeles. The December 30 inspection was conducted in response to a complaint, not as part of a routine survey cycle.
The facility was given the opportunity to submit a plan of correction. The inspection report notes that details of any corrective plan can be obtained by contacting the facility or the California Department of Public Health.
What the record showed was a treatment the nursing director said would not have worked. What actually happened when Resident 1's oxygen levels fell, and whether the right intervention was ever written down anywhere, the inspection report does not say.
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 24, 2026 · Our methodology
ALEXANDRIA CARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on December 30, 2025.
facility on December 30, 2025, following a complaint.
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.