Alexandria Care Center
ALEXANDRIA CARE CENTER in LOS ANGELES, CA — inspection on January 31, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 10's Admission Record (a document containing demographic and diagnostic information), dated 1/30/2025, the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including morbid obesity.
During a review of Resident 10's MAR, dated January 2025, printed 1/29/2025, at1:06 p.m., the MAR indicated that Resident 10 was prescribed and had an active order for:
1.) rivaroxaban (a blood thinner medication used for Deep Vein Thrombosis [DVT - a condition that forms blood clots in the body]) 10 milligram (mg - a unit of measure of mass) tablet to be given orally at bedtime at 9:00 p.m. starting 5/28/2024, and
2.) rivaroxaban 10 mg tablet to be given orally at bedtime at 9 p.m. starting 1/19/2025.
The MAR indicated that both rivaroxaban 10 mg doses were signed off as administered from the following licensed nurses on the following times/dates:
Licensed Vocational Nurse (LVN) 9 - at 9:00 p.m., on 1/20/2025 and 1/21/2025
Registered Nurse (RN) 3 - at 9:00 p.m., on 1/22/2025 and 1/23/2025
LVN 3 -at 9:00 p.m., on 1/24/2025
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 51's Admission Record (a document containing demographic and diagnostic information,) the admission record indicated the facility originally admitted Resident 51 on 3/5/2019 and readmitted the resident on 6/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 11/9/2024, the MDS indicated Resident 51 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial /moderate assistance with personal hygiene and rolling left and right; substantial/maximal assistance with upper body dressing, lower body dressing, , and sit to lying/lying to sitting; total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
The MDS indicated Resident 51 received insulin.
During a review of Resident 51's History and Physical (H&P) dated 6/19/2024, the H&P indicated Resident 51 did not have the capacity to understand and make decisions.
During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:
- 6/11/2024: Insulin glargine-yfgn (Lantus -a long-acting insulin) subcutaneous (SQ - under the skin]) solution pen-injector 100 unit per ml (unit/ml - a unit of measurement) inject 15 units SQ at bedtime for DM.
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 145's Admission Record, the Admission Record indicated the facility admitted the resident on 10/23/2024 and readmitted the resident on 11/23/2024 with diagnoses that included spinal
potential for actual harm radiculopathy (a condition that occurs when a nerve in the spine is damaged or irritated, often called a pinched nerve), cervical region (area at the neck), lack of coordination, and muscle weakness.
During a review of Resident 145's Order Summary Report, the report indicated an order for bed rails as enabler for turning and repositioning in bed, dated 11/23/2024.
During a review of Resident 145's Minimum Data Set (MDS - resident assessment tool) dated 11/29/2024, the MDS indicated the resident was able to understand others and was able to make herself understood.
The MDS further indicated the resident had an impairment on one side of the upper extremities, was dependent on staff for toileting and bathing, and required partial/moderate assistance for personal and oral hygiene.
The MDS indicated the resident required substantial/maximal assistance from staff for transferring from the bed to chair, rolling left to right in the bed, and moving from sitting to lying.
During a concurrent observation and interview on 1/28/2025 at 8:45 a.m., Resident 145 lay in bed with bilateral (both sides) upper siderails in the raised position. Resident 145 stated the siderails are always up.
During a concurrent observation, interview, and record review on 1/30/2025 at 8:45 a.m. with Minimum Data Set Nurse 1 (MDSN 1) and Registered Nurse 1 (RN 1), MDSN 1 and RN 1 reviewed Resident 145's physician orders and care plans. MDSN 1 entered Resident 145's room and stated the resident had bilateral upper siderails in use. RN 1 stated Care Plans are used to provide a resident's care with resident specific interventions and goals. RN 1 stated resident's using SRs should have a CP for the use of SRs. RN 1 stated the importance of the siderail care plan was to know if resident goals, like remaining free of injury from the use of siderails, were met or not met. RN 1 stated Resident 145 did not have a care plan for the use of siderails but should have.
During an interview on 1/31/2025 at 9:30 a.m. with the Director of Nursing (DON), the DON stated resident centered care plans specify resident's specific needs and problems.
The DON stated care plans are followed for each resident to deliver the right intervention for the resident.
The DON stated the facility policy was not followed when Resident 145 did not have a care plan for the use of siderails.
During a review of the facility Policy and Procedure (P&P) titled, Siderails, last reviewed 1/22/2025, the P&P indicated the purpose of the policy was to ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms.
The LN will complete the Bedrail Evaluation and develop a Care Plan reflecting the evaluation.
During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed 1/22/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.
The facility's IDT, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident.
Each resident ' s comprehensive care plan is designed to:
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 51's Admission Record, the Admission Record indicated the facility originally admitted Resident 51 on 3/5/2019 and readmitted the resident on 6/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 11/9/2024, the MDS indicated Resident 51 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial /moderate assistance with personal hygiene and rolling left and right; substantial/maximal assistance with upper body dressing, lower body dressing, , and sit to lying/lying to sitting; total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
The MDS indicated Resident 51 received insulin.
During a review of Resident 51's History and Physical (H&P) dated 6/19/2024, the H&P indicated Resident 51 did not have the capacity to understand and make decisions.
During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:
- 6/11/2024: Insulin glargine-yfgn (Lantus -a long-acting insulin) subcutaneous solution pen-injector 100 unit/ml inject 15 units subcutaneously at bedtime for DM.
- 6/12/2024 to 10/31/2024; 10/31/2024 to 12/6/2024: Insulin lispro MUV 100 unit/ml vial.
Inject subcutaneously before meals and at bedtime for DM.
Inject as per sliding scale: if 140 - 199 = 1; < 70 and conscious glucogel (a gel form of glucose which provides a direct source of sugar 1pack or 4 oz juice, if unconscious, give glucagon IM one time and call MD; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 400 = 5. If blood sugar is greater than 400 mg per deciliter (dl - a unit of measurement) administer 5 units and Call MD.
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027