Alexandria Care Center

F-F656.

Findings:

1. 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 REDACTED] and readmitted on [DATE REDACTED] 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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 LVN 10 - at 9:00 p.m., on 1/25/2025, 1/26/2025, 1/27/2025, and 1/28/2025

Level of Harm - Minimal harm or 2. During a review of Resident 141's Admission Record, the Admission Record indicated Resident 141 was potential for actual harm originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including Afib.

Residents Affected - Some During a review of Resident 141's Order Summary Report, dated 8/22/2024, the Order Summary Report indicated Resident 141 was prescribed Pradaxa 150 mg to give one tablet by mouth every 12 hours for Afib, starting 12/18/2024.

During a review of Resident 141's MAR, dated January 2025, the MAR indicated Resident 141 was prescribed Pradaxa 150 mg to give one tablet by mouth every 12 hours for Afib, at 9:00 a.m. and 9:00 p.m.

The MAR did not contain documentation for the monitoring of side effects of Pradaxa between 1/1/2025 and 1/30/2025.

During a concurrent interview and record review, on 1/30/2025, at 9:30 a.m., with the Director of Nursing (DON), Resident 10's MAR, dated January 2025, was reviewed and the DON stated that Resident 10 had two active orders for rivaroxaban 10 mg starting 1/19/2025. The DON stated the MAR showed both 10 mg doses were documented as given between 1/20/2025 and 1/28/2025. The DON stated that this was due to documentation error and Resident 10 did not receive both doses, since Resident 10 only had one (1) medication supply from the pharmacy for rivaroxaban. The DON stated the physician order on 5/28/2024 needed to be discontinued when a new order for rivaroxaban was prescribed on 1/19/2025. The DON stated that Resident 10 could potentially receive both doses of rivaroxaban if the medication was available and lead to harm by causing excessive bleeding and possibly death. The DON stated the facility failed to identify the duplicate order on the January 2025 MAR starting 1/19/2025.

During a concurrent interview and record review, on 1/30/2025, at 10:08 a.m., with the DON, Resident 141's Care Plan, dated 12/31/2024, was reviewed and the DON stated Resident 141's Care Plan indicated Resident 141 was at risk for complications from Pradaxa, and to monitor for active bleeding. The DON stated monitoring for bleeding would be documented on the MAR and the DON was unable to locate documentation for monitoring for bleeding related to use of Pradaxa for Resident 141 between 1/1/2025 and 1/30/2025. The DON stated that monitoring for bleeding with Pradaxa use was important to ensure Resident 141 does not have bleeding that was unnoticed, which may harm the resident and require hospitalization .

During a review of the facility's policy and procedures (P&P) titled, Physician Orders, last reviewed 1/22/2025, the P&P indicated that the Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary.

During a review of the facility's P&P titled, Medication Utilization and Prescribing - Clinical Protocol, last reviewed 1/22/2025, the P&P indicated:

4. The consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs and symptoms.

3. The staff and practitioners in collaboration with the consultant pharmacist will take into account medication-related issues such as .effects of medication combinations and drug-drug interactions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 During a review of the facility's P&P titled, Medication and Treatment Orders, last reviewed 1/22/2025, the P&P indicated Orders for medications and treatments will be consistent with principles of safe and effective Level of Harm - Minimal harm or order writing. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 Residents Affected - Some Based on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Resident 21 and 358) drug regimen was free from unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (a medication that affects brain activity associated with mental processes and behavior) medications by failing to ensure:

1. Resident 21 had a specific, measurable target behavior related to the use of sertraline (an antidepressant [against depression] medication used for depression or bipolar disorder), starting 12/7/2024.

2. Quetiapine fumarate (an antipsychotic [a class of medication used to treat psychiatric disorders]) and sertraline HCl (a medication to treat depression [persistent feelings of sadness)] were prescribed, administered, and monitored for specific measurable behavioral manifestations for Resident 358.

These deficient practices had the potential to result in unnecessary medication administration and placed Resident 21 and 358 at risk for significant adverse effects (unwanted, unintended result of medications) from

the use of unnecessary antipsychotic medications, including confusion, dizziness, and injuries from falls, resulting in the impairment or decline of residents' mental, physical condition, functional, and psychosocial status.

Findings:

1.a. During a review of Resident 21's Admission Record (a document containing demographic and diagnostic information,) dated 1/30/2025, the Admission Record indicated Resident 21 was originally admitted to the facility on [DATE REDACTED] with a diagnosis that included bipolar.

During a review of Resident 21's Order Summary Report, dated 1/30/2025, the report indicated Resident 21 was prescribed sertraline 50 milligram (mg - a unit of measure of mass) one (1) tablet by mouth daily for depression manifested by sadness, starting 12/7/2024.

During a review of Resident 21's Medication Administration Record ([MAR] - a record of medications administered to residents) for January 2025, the MAR indicated Resident 21 was prescribed sertraline 50 mg one (1) tablet by mouth to be given daily for depression manifested by sadness, at 9 a.m.

During a review of Resident 21's Minimum Data Set (MDS - resident assessment tool), dated 12/13/2024,

the MDS indicated Resident 21 was cognitively (mental action or process of acquiring knowledge and understanding) intact. Resident 21's MDS indicated zero (0) symptoms of having Little interest or pleasure in doing things and zero (0) symptoms in Feeling down, depressed, or hopeless. Resident 21's MDS indicated Resident 21 was taking antidepressants.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a concurrent record review and interview on 1/30/2025 at 2:12 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 21's MDS and MAR. The DON stated the MDS did not indicate that Level of Harm - Minimal harm or Resident 21 was depressed, and the January 2025 MAR indicated the sertraline order did not include potential for actual harm monitoring for a specific type of behavior and condition. The DON stated sadness was not considered a behavior but rather an emotion. The DON stated the monitoring of sadness for sertraline use was unclear Residents Affected - Some and open to interpretation by different licensed nurses. The DON stated not having specific behavior and condition monitoring could result in inaccurate assessment by the physician for the effectiveness of Resident 21's sertraline therapy. The DON stated that the facility failed to have individualized, person-centered care by monitoring a non-specific behavior for Resident 21, potentially resulting in the use of unnecessary psychotropic medication.

44244

1.b. During a review of Resident 358's Admission Record, the Admission Record indicated the facility admitted the resident on 1/9/2025 with diagnoses that included depression, dementia (a progressive state of decline in mental abilities), and a history of falls.

During a review of Resident 358's MDS dated [DATE REDACTED], the MDS indicated the resident sometimes was able to understand others and sometimes was able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, showering, dressing, and transferring from the bed to the toilet or shower. The MDS indicated the resident was taking antipsychotic and antidepressant medication.

During a review of Resident 358's Order Summary Report, the report indicated the following orders:

- Quetiapine fumarate oral tablet 50 mg, give one tablet by mouth three times a day for agitation, dated 1/9/2025.

- Anti-psychotic: monitor episodes of agitation every shift, dated 1/9/2025.

- Sertraline HCl oral tablet 100 mg , give one tablet by mouth one time a day for depression manifested by unhappiness, dated 1/9/2025.

- Anti-depressant: monitor episodes of unhappiness every shift, dated 1/9/2025.

During a review of Resident 358's Care Plan (CP) titled, Resident is at risk for complications related to the use of psychotropic drugs . Medication: Sertraline . Quetiapine ., initiated on 1/10/2025, the CP indicated a goal that the resident will have the smallest most effective dose without side effects.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a concurrent interview and record review on 1/30/2025 at 2:21 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 reviewed Resident 358's physician orders and Medication Administration Level of Harm - Minimal harm or Record. MDSC 1 stated psychotropic medications affect the mind and behavior of residents. MDSC 1 stated potential for actual harm psychotropics are considered high risk medications for the elderly because there was the potential for side effects like death of the resident from polypharmacy (the regular use of five or more medications at the same Residents Affected - Some time and is common in older adults). MDSC 1 stated psychotropic medication use must be monitored to ensure the resident has behaviors that warrant the use of the medication. MDSC 1 stated the goal is to eliminate the medication or lower the dose to prevent adverse effects. MDSC 1 stated Resident 358's quetiapine fumarate was ordered for the behavior manifestation of agitation. MDSC 1 stated agitation is very general and is not descriptive of a specific behavior to monitor like outbursts or restlessness. MDSC 1 stated Resident 358's sertraline was prescribed with the behavior manifestation of unhappiness. MDSC 1 stated unhappiness is very general and is not descriptive of a specific behavior like verbalization of sadness. MDSC 1 stated the admitting nurse or the interdisciplinary team should have clarified with the physician to indicate specific behavioral manifestations to monitor, but they did not.

During a concurrent interview and record review on 1/31/2025 at 9:30 a.m. with the DON, the DON reviewed

the facility policy and procedures regarding psychotropic medications. The DON stated agitation and unhappiness are not specific behavioral manifestations for the use of psychotropics. The DON stated there must be specific, targeted behaviors to monitor and evaluate for the possibility of a gradual dose reduction (GDR) of a resident's psychotropic medication. The DON stated GDRs are important to lessen the chance of side effects from unnecessary medications. The DON stated when unnecessary psychotropic medications are administered there is a high risk for side effects like falls that may result in fractures. The DON stated the facility policy was not followed when Resident 358's psychotropic medications were not ordered with specific behavioral manifestations to monitor.

During a review of facility Policy and Procedures (P&P,) titled Psychotropic Medication Use, by SNF Clinic, last revised July 2022, the P&P indicated: Residents will not receive medications that are not clinically indicated to treat a specific condition.

1. A Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.

2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications:

a. Anti-psychotics

b. Anti-depressants

3. Psychotropic medication management includes:

a. Indications for use

d. Adequate monitoring for efficacy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 4. Residents who have not used psychotropic medications are not prescribed or given these medications unless it is determined to be necessary to treat a specific condition that is diagnosed and documented in the Level of Harm - Minimal harm or clinical record. potential for actual harm 8. Consideration of the use of any psychotropic medication is based on a comprehensive review of the Residents Affected - Some resident. This includes evaluation of the resident's signs and symptoms to identify underlying causes.

3. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The evaluation will attempt to clarify whether: signs and symptoms are clinically significant enough to warrant medication therapy.

During a review of the facility's P&P titled Psychotropic Medication Use, by Skilled Nursing Pharmacy, with

an effective date June 2021, the P&P indicated that A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which includes but is not limited to antipsychotics, anxiolytics, hypnotics and antidepressants. The Facility should comply with the State Operations Manual, and all other Applicable Law relating to the use of psychoactive medications, including gradual dose reductions.

1c. Staff should become familiar with .the resident to .reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that maybe indicated for a specific behavior type.

3. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five (5) percent (%). Three (3) medication errors out of 29 total opportunities contributed to an overall medication error rate of 10.35% affecting two (2) of five (5) residents observed for medication administration (Resident 109 and 257). The medication errors were as follows:

1. Resident 257 did not receive a form of aspirin (a medication used to treat peripheral vascular disease [PVD - a condition that affects blood vessels] and Deep Vein Thrombosis [DVT - a condition that forms blood clots in the body] in those with atrial fibrillation [an irregular, fast heart rate]) as ordered by Resident 257's physician.

2. Resident 109 received metformin (a medication used to treat high blood sugar levels) and aspirin at a different time than ordered by Resident 109's physician.

These failures had the potential to result in Resident 257 and Resident 109 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and had the potential to result in residents' health and well-being to be negatively impacted.

Findings:

1. During a review of Resident 257's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE REDACTED] with diagnoses including atrial fibrillation.

During a review of Resident 257's Order Summary Report, dated 1/28/2025, the Order Summary Report indicated Resident 109 was prescribed aspirin 81 milligram (mg - a unit of measure of mass) enteric coated (EC - a form of aspirin that is designed to slowly release medication) tablet once a day for DVT prophylaxis (prevention) starting 1/25/2025.

During a review of Resident 257's Medication Administration Record (MAR - a record of mediations administered to residents), dated January 2025, the MAR indicated Resident 257 was prescribed aspirin 81 mg EC tablet to be given once a day orally for DVT prophylaxis at 9:00 a.m.

During an observation, on 1/28/2025, at 8:59 a.m., in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 5 administered aspirin 81 mg chewable tablet to Resident 257. Resident 257 swallowed the aspirin tablet with glass of juice.

During an interview, on 1/28/2025, at 1:15 p.m., with LVN 5, LVN 5 stated that LVN 5 administered aspirin 81 mg chewable tablet during the morning medication administration at 8:59 a.m. to Resident 257. LVN 5 stated that LVN 5 failed to follow the physician orders to administer aspirin 81 mg EC tablet. LVN 5 stated this was considered a medication error, and that there was a risk for stomach irritation to 257 when the EC form was not given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 2. During a review of Resident 109's Admission Record, the Admission Record indicated the resident was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including Diabetes Level of Harm - Minimal harm or Mellitus 2 (DM2 - a condition where there are high blood sugar levels.) potential for actual harm

During a review of Resident 109's Order Summary Report, dated 1/28/2025, the Order Summary Report Residents Affected - Some indicated Resident 109 was prescribed aspirin 81 mg once a day for PVD starting 6/13/2024, and metformin 500 mg twice a day for diabetes starting 6/6/2024.

During a review of Resident 109's MAR, dated January 2025, the MAR indicated Resident 109 was prescribed aspirin 81 mg to be given once a day orally for PVD at 8:00 a.m., and metformin 500 mg to be given twice a day orally for diabetes at 7:00 a.m. and 5:00 p.m.

During an observation, on 1/28/2025, at 9:40 a.m., in Medication Cart Station 2, LVN 1 administered aspirin 81 mg tablet and metformin 500 mg tablet to Resident 109. Resident 109 swallowed the aspirin and metformin tablet with glass of water.

During an interview, on 1/28/2025, at 12:45 p.m., with LVN 1, LVN 1 stated that LVN 1 administered aspirin 81 mg tablet and metformin 500 mg tablet during the morning medication administration at 9:40 a.m. to Resident 109. LVN 1 acknowledged the physician's order specified to administer metformin at 7:00 a.m. and aspirin at 8:00 a.m. LVN 1 stated, per facility policy, there was a 60-minute window for medication administration and LVN 1 administered the metformin and aspirin later than that timeframe. LVN 1 stated

these were considered medication errors.

During an interview, on 1/30/2025, at 2:18 p.m., with the Director of Nursing (DON), the DON stated LVN 5 failed to administer aspirin 81 mg EC tablet to Resident 109, and LVN 1 failed to administer metformin 500 mg tablet and aspirin 81 mg tablet to Resident 257 at the scheduled time, according to the physician orders.

The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications at the right times are administered to residents. The DON stated Resident 109 may be at risk for developing stomach irritation from receiving aspirin 81 mg chewable tablet, and Resident 257 may be at risk of stomach irritation from receiving the metformin at 9:40 a. m. without a meal.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed 1/22/2025, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed.

4. Medications are administered in accordance with prescriber orders, including any required time frame.

7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

9. The individual administering the medication checks to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

During a review of the facility's P&P titled, Medication Errors, last reviewed 1/22/2025, the P&P indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 b. Medication Error means the administration of medication:

Level of Harm - Minimal harm or At the wrong time potential for actual harm Which is not currently prescribed. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three (3) of three (3) sampled residents (Resident 51, 129 and 137) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites.

This deficient practice increased the risk that Residents 51, 129 and 137 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross Reference

F-F658

Findings:

1. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 - 6/12/2024 to 10/31/2024; 10/31/2024 to 12/6/2024: Insulin lispro MUV 100 unit/ml vial. Inject SQ before meals and at bedtime for DM. Inject as per sliding scale: if 140 - 199 = 1; < 70 and conscious glucogel (a gel Level of Harm - Minimal harm or form of glucose which provides a direct source of sugar 1pack or 4 ounce ([oz - a unit of measurement]) potential for actual harm juice, if unconscious, give glucagon intramuscular ([IM - into the muscle tissue]) 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 Residents Affected - Some unit of measurement) administer 5 units and Call MD.

- 12/6/2024: INSULIN LISPRO MUV 100 UNIT/1ML VIAL Inject SQ before meals and at bedtime for DM inject within 15 mins before meal or with first bite of meal. Inject as per sliding scale (insulin dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level): if 140 - 199 = 1; < 70 and conscious glucogel 1pack or 4 oz juice, if unconscious, 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 (> - a unit of measurement) 400 mg per deciliter (dl - a unit of measurement) = give 5 units and call MD.

During a concurrent interview and record review on 1/30/2025 at 11:15 a.m., Resident 51's Order Summary Report, MAR, Location of Administration Report for 12/2024 and 1/2025 was reviewed with LVN 2, LVN 2 verified Resident 51 had a physician's order for insulin lispro and insulin glargine and were administered as follows:

- Insulin glargine-yfgn SQ solution pen-injector 100 unit/ml

12/05/24 9:30 p.m. SQ Abdomen - LUQ

12/06/24 9:27 p.m. SQ Abdomen - LUQ

12/12/24 9:13 p.m. SQ Abdomen - LUQ

12/13/24 9:23 p.m. SQ Abdomen - LUQ

12/19/24 10:08 p.m. SQ Arm - left

12/20/24 8:59 p.m. SQ Arm - left

12/21/24 9:21 p.m. SQ Abdomen - RLQ

12/22/24 9:50p.m. SQ Abdomen - RLQ

12/26/24 9:24 p.m. SQ Abdomen - LUQ

12/27/24 9:34 p.m. SQ Abdomen - LUQ

1/16/25 9:00 p.m. SQ Abdomen - LUQ

1/17/25 10:00 p.m. SQ Abdomen - LUQ

1/18/25 8:23 p.m. SQ Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 1/19/25 8:56 p.m. SQ Abdomen - RLQ

Level of Harm - Minimal harm or 1/20/25 9:37 p.m. SQ Abdomen - RLQ potential for actual harm 1/21/25 9:09 p.m. SQ Abdomen - left lower quadrant (LLQ) Residents Affected - Some 1/22/25 9:43 p.m. SQ Abdomen - LLQ

- Insulin lispro MUV 100 unit/ml vial:

12/06/24 11:28 a.m. SQ Arm - left

12/07/24 11:26 a.m. SQ Arm - left

LVN 2 stated insulin administration sites should be rotated per standards of practice and manufacturer's guidelines. LVN 2 verified Resident 51's MAR indicated the insulin administration sites were not rotated. LVN 2 stated Resident 51's insulin administration sites should have been rotated per the manufacturer's guidelines and standards of practice to prevent pain, redness, irritation, and bumps or lumps on the resident's skin. LVN 2 stated not rotating the administration sites can be considered a medication error by not following the manufacturer's guideline and standards of practice.

During an interview on 1/30/2025 at 3 p.m. with DON, the DON stated 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 Resident 51's insulin administration site should have been rotated as it placed the resident at risk for pain bruising, lipodystrophy, and amyloidosis. The DON stated not rotating insulin administration sites can be considered a medication error due to not following the standards of practice and manufacturer's guideline.

During a review of the facility's policy and procedure (P&P) tilted, Insulin Administration, last reviewed 1/25/2025, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided manufacturer's guideline on Lantus (insulin glargine, last revised on 6/2023, the manufacturer's guideline indicate to administer Lantus SQ into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into the areas of lipodystrophy or localized cutaneous amyloidosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of the facility provided manufacturer's guideline on, Insulin Lispro Kwikpen, last reviewed on 1/25/2025, the manufacturer's guideline indicated to change or rotate injection sites within the area with each Level of Harm - Minimal harm or dose to reduce the risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous potential for actual harm amyloidosis (skin with lumps) at the injection sites.

Residents Affected - Some - Do not the exact same spot for each injection.

- 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.

2. During a review of Resident 137's Admission Record, the admission record indicated the facility originally admitted Resident 137 on 5/21/2024 and readmitted the resident on 1/9/2025, with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), DM2, and generalized muscle weakness.

During a review of Resident 137's MDS dated [DATE REDACTED], the MDS indicated Resident 137 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living ADLs. The MDS indicated Resident 137 received insulin.

During a review of Resident 137's H&P dated 1/12/2025, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

During a review of Resident 137's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:

- 12/1/2024 to 12/10/2025; 12/10/2024 to 1/9/2025: Insulin lispro (a short acting insulin) injection solution inject SQ before meals and at bedtime for DM 2 to inject 15 minutes before meals or with first bite of the meal. Inject as per sliding scale: if 71 - 150 = 0 ; less than (< - a unit of measurement) 70 if patient is conscious, give four (4) oz of juice. If unconscious, give glucagon 1 mg IM one time. Notify MD; 151 - 200 = 1 unit; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 6; above 401 = 8.

- 1/9/2025: Insulin lispro injection solution inject SQ before meals and at bedtime for DM 2. Inject as per sliding scale: if 151 - 200 = 1; if blood sugar is < 70 and conscious give 4 oz of juice. If unconscious give glucagon 1mg IM one time and notify MD; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 6 if blood sugar above 400, give 8 units and notify MD for DM 2.

- 9/6/2024 to 12/1/2024: Insulin glargine (Lantus - a long-acting insulin) SQ solution 100 unit/ml inject 50 units SQ two times a day for DM 2.

- 1/9/2025: Lantus solostar subcutaneous solution pen-injector 100 unit/ml. inject 40 units SQ two times a day for DM 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a concurrent interview and record review on 1/30/2025 at 11 a.m., Resident 137's Order Summary Report, MAR, Location of Administration Report for 12/2024 and 1/2025 was reviewed with Licensed LVN 2, Level of Harm - Minimal harm or LVN 2 verified Resident 137 had a physician's order for insulin lispro and Lantus and were administered as potential for actual harm follows:

Residents Affected - Some - Insulin lispro injection solution:

12/02/24 9:02 p.m. SQ Arm - right

12/03/24 6:06 a.m. SQ Arm - right

12/04/24 5:07 p.m. SQ Abdomen - left upper quadrant (LUQ)

12/04/24 9:14 p.m. SQ Abdomen - LUQ

12/11/24 12:22 p.m. SQ Arm - left

12/11/24 6:06 p.m. SQ Arm - left

12/11/24 9:11 p.m. SQ Arm - right

12/12/24 6:11 a.m. SQ Arm - right

12/14/24 8:24 p.m. SQ Abdomen - LUQ

12/15/24 5:26 p.m. SQ Abdomen - LUQ

12/18/24 11:46 a.m. SQ Abdomen - right lower quadrant (RLQ)

12/18/24 4:30 p.m. SQ Abdomen - RLQ

1/22/25 4:36 p.m. SQ Arm - right

1/22/25 9:22 p.m. SQ Arm - right

1/23/25 5:59 a.m. SQ Arm - left

1/23/25 11:50 a.m. SQ Arm - left

1/24/25 6:16 a.m. SQ Arm - left

- Lantus solostar SQ solution pen-injector 100 unit/ml

1/19/25 10:47 a.m. SQ Abdomen - RLQ

1/19/25 9:12 p.m. SQ Abdomen - RLQ

12/18/24 9:00 p.m. SQ Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 12/19/24 9:33 p.m. SQ Abdomen - LUQ

Level of Harm - Minimal harm or LVN 2 stated insulin administration sites should be rotated per standards of practice and manufacturer's potential for actual harm guidelines. LVN 2 verified Resident 137's MAR indicated the insulin administration sites were not rotated. LVN 2 stated Resident 137's insulin administration sites should have been rotated per the manufacturer's Residents Affected - Some guidelines and standards of practice to prevent pain, redness, irritation, and bumps or lumps on the resident's skin. LVN 2 stated not following manufacturer's guideline and standards of practice of rotating insulin administration sites can be considered a medication error.

During an interview on 1/30/2025 at 3 p.m. with DON, the DON stated 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 Resident 137's insulin administration site should have been rotated as it placed the resident at risk for pain bruising, lipodystrophy, and amyloidosis. The DON stated not rotating insulin administration sites can be considered a medication error due to not following the standards of practice and manufacturer's guideline.

During a review of the facility's policy and procedure (P&P) tilted, Insulin Administration, last reviewed 1/25/2025, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided manufacturer's guideline on Lantus (insulin glargine, last revised on 6/2023, the manufacturer's guideline indicate to administer Lantus SQ into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into the areas of lipodystrophy or localized cutaneous amyloidosis.

During a review of the facility provided manufacturer's guideline on, Insulin Lispro Kwikpen, last reviewed on 1/25/2025, the manufacturer's guideline indicated to change or rotate injection sites within the area with each dose to reduce the risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

- Do not the exact same spot for each injection.

- 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.

43455

3. During a review of Resident 129's Admission Record dated 1/30/2025, indicated the resident was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including DM2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 129's Order Summary Report, dated 1/30/2025, indicated Resident 129 was prescribed Regular (short-acting insulin) insulin to inject per sliding scale, SQ before meals and at bedtime Level of Harm - Minimal harm or related to DM2, starting 4/15/24. potential for actual harm

During a review of Resident 129's Medication Administration Record ([MAR] - a record of mediations Residents Affected - Some administered to residents) for January 2025, the MAR indicated Resident 129 was prescribed Regular insulin to inject per sliding scale SQ before meals and at bedtime related to DM2, at 6:30 a.m., 11:30 a.m., 4:30 p. m. and 9 p.m.

During the same review, the MAR indicated Regular Insulin was administered SQ by the following licensed vocational nurse (LVN)s, on the following days, times, and sites:

1/12/25 two (2) un at 11:30 a.m. on left arm by LVN 6

1/12/25 two (2) un at 4:30 p.m. on left arm by LVN 7

1/12/25 two (2) un at 9 p.m. on left arm by LVN 7

1/16/25 two (2) un at 11:30 a.m. on left arm by LVN 6

1/16/25 two (2) un at 9 p.m. on left arm by LVN 8

During a concurrent interview and record review on 1/30/2025 at 2:18 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 129's MAR for January 2025. The DON stated that Resident 129's MAR indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 129 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. The DON stated not rotating insulin administration sites was considered a significant medication error.

During a review of the facility's policy and procedure (P&P) tilted, Insulin Administration, last reviewed 1/25/2025, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

c. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

d. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of facility provided manufacturer's guide Highlights of Prescribing Information for Humulin R (brand name for Regular insulin) dated June 2023, the guide indicated to Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 43455 Residents Affected - Some Based on observation, interview, and record review the facility failed to:

1. Store seven (7) ipratropium with albuterol (a combination medication used to treat and prevent shortness of breath) inhalation solutions in the foil pack (package made of foil protecting the inhalation solution from light and degradation) for Resident 72, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 1 T2).

2. Remove and discard from use one (1) expired eye drop medication bottle for Residents 115 in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 2 T).

3. Store or label one (1) insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial for Resident 258, in accordance with manufacturer's requirements in one (1) of four (4) inspected medication carts (Medication Cart Station 1 T2).

4. Remove and discard from use two (2) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]) vials for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1).

These deficient practices increased the risk that Residents 72, 115 and 258 could receive medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Findings:

During a concurrent observation and interview, on 1/29/2025, at 11:10 a.m., in Medication Cart Station 1 T2, with Licensed Vocational Nurse (LVN) 4, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:

1. One (1) open ipratropium with albuterol combination inhalation solution foil pouch for Resident 72, was found stored at room temperature and labeled with a date indicating inhalation solution was removed from foil pouch on 1/5/2025. Seven (7) inhalation solutions were stored outside the foil pouch.

The manufacturer's product storage and labeling indicated opened foil pouches of ipratropium with albuterol inhalation solutions should always be stored in the foil pouch at room temperature between 36 and 77 degrees Fahrenheit and used or discarded within two weeks of being removed from foil pouch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 2. One (1) unopened insulin Humulin R vial for Resident 258 was found stored at room temperature without a date indicating when storage at room temperature began. Level of Harm - Minimal harm or potential for actual harm The label on the prescription bottle indicated to discard unused medication after 31 days. The manufacturer's product labeling indicated unopened Humulin R vials should be stored in the refrigerator room between 36 Residents Affected - Some and 46 degrees Fahrenheit and discarded after 31 days once stored at room temperature.

LVN 4 stated the ipratropium with albuterol inhalation solution foil pack for Resident 72 was opened and seven (7) inhalation solutions were stored outside the foil pouch in Medication Cart Station T2 with a date indicating the pouch was opened on 1/5/2025. LVN 4 stated according to the manufacturer guidelines the inhalation vials needed to remain in the foil pouch or when stored outside the pouch discarded within two (2) weeks. LVN 4 stated seven (7) ipratropium with albuterol inhalations were considered expired after 1/19/2025. LVN 4 stated giving expired ipratropium with albuterol can be ineffective in treating the shortness of breath for Resident 72, exacerbate (make worse) the situation leading to stoppage of breathing. LVN 4 stated seven (7) the ipratropium with albuterol inhalation vials for Resident 72 should be discarded from Medication Cart Station 1 T2.

LVN 4 stated Resident 258's Humulin R vial was stored at room temperature and not opened and should have either been stored in the refrigerator until opened or labeled with a date when storage at room temperature began. LVN 4 stated it was unknown when the Humulin R vial was stored at room temperature therefore unknown when it would expire and need to be discarded. LVN 4 stated open multi-dose (containing more than one dose) medications like insulins are usually good for 28 days and lose potency (effectiveness) and expire beyond that date, and, if not labeled, the expired insulin can be used in error. LVN 4 stated the Humulin R vial needed to be discarded and replaced with a new one from pharmacy to ensure expired insulin was not administered in error to Resident 258. LVN 4 stated administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 258 by causing high blood sugar levels leading to coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels) and hospitalization .

During a concurrent observation and interview, on 1/29/2025, at 11:24 a.m., in Medication Cart Station 2 T, with LVN 2, the medication below was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies:

One open dorzolamide (a medication used to decrease pressure in the eye caused by glaucoma [type of eye disease]) eye drop bottle for Resident 115 was found stored at room temperature and labeled with a date indicating use began on 12/27/2024. The label on the prescription bottle indicated to discard unused portion

after 28 days.

LVN 2 stated the dorzolamide eye drop bottle for Resident 115 was opened on 12/27/2024 and according to

the label on the bottle it needed to be discarded after 28 days, which would be on 1/25/2025. LVN 2 stated

the dorzolamide eye bottle for Resident 115 was considered expired, and administering expired eye drops would not be effective in treating Resident 115's eye condition as the medication had lost potency and can potentially lead to eye infections as the bottle was no longer sterile beyond the 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a concurrent observation and interview, on 1/3/2025, at 12:15 p.m., with Registered Nurse (RN) 1, in Medication Room Station 1, the medication below was found either expired and not discarded, or stored Level of Harm - Minimal harm or contrary to their respective manufacturer's specifications and facility policies and procedures: potential for actual harm Two (2) open Aplisol multi-dose vial for facility stock was found stored in the refrigerator and not labeled with Residents Affected - Some a date indicating when use began. The manufacturer's product storage and labeling indicated Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial.

RN 1 stated two (2) Aplisol vial stored in the refrigerator in Medication Room Station 1 were opened, used, and not labeled with a date indicating when use began. RN 1 stated open Aplisol vials were good for 30 days. RN 1 stated Aplisol vials need to be labeled with a date when first used to know when to discard and not administer expired Aplisol to residents in error. RN 1 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to residents. RN 1 stated both vials were considered expired and needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents.

During an interview, on 1/30/2025, at 2:18 p.m., with the Director of Nursing (DON), the DON stated that ipratropium with albuterol inhalation vials needed to be discarded after two (2) weeks when stored outside

the foil pack, unopened insulin Humulin R vials needed be stored in the refrigerator or labeled with a date when stored at room temperate, and eye drop bottles removed from medication carts are discarded after 28 days of use. The DON stated medications that are not stored according to manufacturer guidelines were considered expired. The DON stated expired medications have lost their potency and will not be effective in treating a resident's condition. The DON stated that several licensed nurses failed to remove expired dorzolamide bottle for Resident 115 from Medication Cart Station 2 T, store ipratropium with albuterol inhalation vials for Resident 72 inside the foil pouch, and label Humulin R vial with an open date for Resident 258 in Medication Cart Station 1 T2, according to facility and manufacturer guidelines. The DON stated these failures could potentially lead to the administration of expired medication to residents. The DON stated administering expired ipratropium with albuterol to Resident 72 will not treat the shortness of breath, exacerbating (making worse) the shortness of breath potentially leading to stoppage of breathing and hospitalization . The DON stated administering expired eye drop to Resident 115 will not be effective in treating the resident's eye condition and potentially cause eye infections. The DON stated administering expired insulin will not be effective in controlling blood sugar levels and can harm Resident 258 by causing high or low blood sugar levels, leading to coma and hospitalization . The DON stated that two (2) Aplisol vial were opened and not labeled with a date when use began and stored in the medication refrigerator for facility stock use. The DON stated multi-dose vials (used more than once) usually expire 28 days after opening the vials and should be discarded beyond that date to prevent accidental use. The DON stated both Aplisol vials were considered expired and needed to be removed from the medication room and be discarded to prevent accidental use. The DON stated using Aplisol vials beyond the expiration date in error may potentially provide inaccurate results for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) leading to inaccurate treatment for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a review of the facility's policy and procedures (P&P) titled, Administering Medications, last reviewed 1/22/2025, the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. Level of Harm - Minimal harm or potential for actual harm 11. The expiration/beyond use date on the medication label is checked prior to administering. When opening

a multi-dose container, the date opened is recorded on the container. Residents Affected - Some

During a review of the facility's P&P titled, Storage of Medications, last reviewed 1/22/2025, the P&P indicated: The facility stores all drugs and biologicals in a safe, secure and orderly manner.

1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

4. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

During a review of the facility's P&P titled, Medication Labeling and storage, last reviewed 1/22/2025, the P&P indicated: The facility stores all medications and biologicals in locked compartments under proper temperature, light and humidity controls.

2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

5. Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of:

a. Twenty seven (27) of 27 residents on puree diet (diet consisting of food with soft pudding-like consistency) and 15 of 15 residents on soft mechanical diet (diet consisting of chopped and soft foods), received less portion for pureed rice and pureed corn as staff did not level off number eight (#8, 1/2 cup) scoop.

b. Seven (7) of 7 residents on puree diet and ten (10) of 10 resident on regular texture (no restriction) got mashed potatoes with their tacos in substitution for rice.

c. 1 of 1 sampled resident had no alternate menu posted in Station 3 and the room.

These failures had the potential to result in decreased food and nutrient intake resulting to unintended (not planned) weight loss.

Findings:

a. During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled Diet Guide Sheet, dated 1/28/2025, the spreadsheet indicated residents on dysphagia puree diet would include the following foods in the tray:

- Pureed chicken fajita 1/2 cup (c, a household measurement)

- Pureed cream style corn 1/2 c

- Pureed steamed rice 1/2 c

- Pureed sliced pears 1/2 c

During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled, Diet Guide Sheet, dated 1/28/2025, the spreadsheet indicated residents on dysphagia soft mechanical diet would include the following foods in the tray:

- Pureed chicken fajita 1/2 cup (c, a household measurement)

- Pureed cream style corn 1/2 c

- Pureed steamed rice 1/2 c

- Sliced pears 1/2 c

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During an observation on 1/28/2025 at 12:03 p.m. of the trayline (an area where foods were assembled from

the steamtable to the trays), observed cook not leveling off #8 scoop for pureed rice and pureed corn for soft Level of Harm - Minimal harm or mechanical and puree diets. potential for actual harm

During an observation on 1/28/2025 at 12:45 p.m. of the trayline, observed cook not leveling off #8 scoop for Residents Affected - Some pureed rice and pureed corn for soft mechanical and puree diets giving less portions.

During an observation on 1/28/2025 at 12:53 p.m. of the trayline, observed trayline was running out of soft mechanical chicken fajita and cook was not leveling the #8 scoop full giving less portions.

During an interview on 1/28/2025 at 1:41 p.m. with the Dietary Supervisor (DS), the DS stated the spreadsheet indicated portion sizes of food and the right portion size was for staff to fill up the scoop and level it off. The DS stated if staff was not filing the #8 scoop and leveling it off, they were giving the residents less portions. The DS stated if residents received less portions, then the residents would not get the right amount of nutrition causing long term weight loss as a potential outcome.

During an interview on 1/29/2025 at 3:20 p.m., with the Registered Dietitian (RD), the RD stated a correct portion size is filling up the scoop and leveling it off. The RD stated if the scoop was not filled and leveled off, there would be less portion size and less calories for the meal provided affecting resident's caloric intake.

The RD stated weight loss, delay in wound healing as a long tern effect would be the potential outcome.

During a review of the facility's recipe titled, Tortilla, Flour (6 inches)- 1 each, undated, the recipe indicated portion size of puree corn was 1/2 c.

During a review of the facility's policy and procedure (P&P) titled Menus, dated 1/22/2025, the P&P indicated, Menus will be planned to meet the nutritional needs of the residents/patients in accordance with

the established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Facility unable to provide specific policy for portion sizes when requested.

b. During a review of Resident 91's Admission Record, the Admission Record indicated the facility initially admitted Resident 91 on 12/24/2021 and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes mellitus (DM 2, a disorder characterized by difficulty of blood sugar control and would healing), chronic kidney disease stage 3 (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).

During a review of Resident 91's Minimum Data Set (MDS- a resident assessment tool), dated 11/12/2024,

the MDS indicated Resident 91 usually made self understood and understand others. The MDS further indicated Resident 91 required set up and clean up assistance with eating while a resident of the facility and within the last seven days.

During a review of Resident 91's Order Summary Report, dated 4/23/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (a diet containing the same amount of carbohydrates per meal for blood sugar management), regular texture (no restriction) and no salt on tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During an interview on 1/28/2025 at 10:20 a.m. with Resident 91, Resident 91 stated the food sucks, and would not feed this food to a dog. Resident 91 stated having already spoken to the kitchen staff (not Level of Harm - Minimal harm or identified) about the food quality, but nothing was changed. potential for actual harm

During a review of the facility's menu spreadsheet titled, Diet Guide Sheet, dated 1/28/2025, the spreadsheet Residents Affected - Some indicated residents on regular diet (no restrictions) would include the following foods in the tray:

- Chicken fajita with flour tortilla two (2) each

- Chuckwagon corn 1/2 c

- Steamed rice 1/2 c

- Sliced pears 1/2 c

During an observation on 1/28/2025 at 12:53 p.m. of the food in trayline, observed puree rice and regular rice ran out and was substituted with mashed potatoes.

During an observation on 1/28/2025 at 1:15 p.m., seven (7) puree trays got mashed potato instead of puree rice while the diet ticket indicated puree rice to be served to the resident. Observed ten (10) regular texture diet trays received mashed potatoes instead of steamed rice.

During an interview on 1/28/2024 at 1:31 p.m. with the DS and District Manager (DM), the DM stated the cook did not make enough rice, but the uncooked rice is available. DM stated they substituted rice with mashed potatoes, and it was a weird combination with tacos. DM stated resident would be discontent and would complain as a potential outcome. The DS stated residents would not eat causing weight loss as a potential outcome.

During an interview on 1/29/2025 at 3:23 p.m. with the RD, the RD stated rice, and mashed potato has similar carbohydrate content as a substitute, however, when looking at overall menu compatibility, tacos and mashed potatoes combination in a meal would not be ideal, and it could dissatisfy residents as they were expecting certain food (steamed rice) but got other food items. The RD stated residents would not eat the food as a potential outcome.

During a review of the facility's P&P titled, Menus, dated 1/22/2025, the P&P indicated, (6) Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

During a review of the facility's P&P titled, Food: Quality and Palatability, dated 1/22/2025, the P&P indicated, (1) The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to menus, production guidelines, and standardized recipes. (4) The cook(s) prepare food

in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate.

During a review of the facility's P&P titled, Standardized Recipes, dated 1/22/2025, the P&P indicated, (2) Standardized Recipes will be adjusted to the number of portions required for a meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 c. During a review of Resident 128's Admission Record, the Admission Record indicated the facility initially admitted Resident 128 on 12/28/2023 and readmitted on [DATE REDACTED] with diagnoses including essential Level of Harm - Minimal harm or hypertension, pleural effusion (a buildup of fluid between the lungs and chest cavity), and hyperlipidemia potential for actual harm (high fat in the blood).

Residents Affected - Some During a review of Resident 128's MDS, dated [DATE REDACTED], the MDS indicated Resident 128 usually made self understood and understand others. The MDS further indicated Resident 128 required supervision and touching assistance (helper provides verbal cues and touch as resident completes the activity) with eating while a resident of the facility and within the last seven days.

During a review of Resident 128's Order Summary Report, dated 12/16/2024, the Order Summary Report indicated a physician's order for regular diet (no restriction).

During an interview on 1/28/2025 at 11:00 a.m. with Resident 128, Resident 128 stated there were not much food choices and he wanted chicken and fish, but he was not getting his request. Resident 128 stated alternate menu was not available, and he did not know where to find it.

During an interview on 1/28/2025 at 11:10 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated alternate menu was suppose to be posted by the Station 3 menu board. CNA 2 stated the menu board did not have menu posted that was readable and the alternate menu was not posted on the board.

During an interview on 1/28/2025 at 11:12 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the menus were not posted on the three (3) slots intended for menus instead they are in the bottom of the board that were not readable as they were too small and sometimes blocked by the medication cart. LVN 2 stated it was important to post the menus and alternate menus so residents could be reminded of the food served that day and could ask for alternate menu if they changed their minds and if they did not like the food they received.

During an interview on 1/30/2025 at 4:30 p.m. with LVN 2, LVN 2 stated there was no visible copy of the weekly menu on the side of Resident 128's room and there was no alternate menu posted. LVN 2 stated it was important that both menus were posted in the resident's room.

During a review of the facility's P&P titled, Menus, dated 1/22/2025, the P&P indicated, (8) Menus will be posted in the Dinning Services department, dining rooms, and resident/patient care areas.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that Residents Affected - Some conserved appetizing temperature when sliced pears were dished out at 11:45 a.m. with temperature of 68 degrees Fahrenheit ( F, a degree of temperature) and the coleslaw was left out in trayline from 12:00 to 12:25 p.m. with a temperature of 75 F.

This failure had a potential to result in 149 of 155, including Resident 91, facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Findings:

a. During a review of Resident 91's Admission Record, the Admission Record indicated the facility initially admitted Resident 91 on 12/24/2021 and readmitted on [DATE REDACTED] with diagnoses including type 2 diabetes mellitus (DM 2, a disorder characterized by difficulty of blood sugar control and would healing), chronic kidney disease stage 3 (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition).

During a review of Resident 91's Minimum Data Set (MDS- a resident assessment tool), dated 11/12/2024,

the MDS indicated Resident 91 usually made self understood and understand others. The MDS further indicated Resident 91 required set up and clean up assistance with eating while a resident of the facility and within the last seven days.

During a review of Resident 91's Order Summary Report, dated 4/23/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (a diet containing the same amount of carbohydrates per meal for blood sugar management), regular texture (no restriction) and no salt on tray.

During an interview on 1/28/2025 at 10:20 a.m. with Resident 91, Resident 91 stated the hot food was cold and the cold food was hot when served. Resident 91 sated the spaghetti and eggs the kitchen served was cold.

During a review of the facility's menu spreadsheet titled, Diet Guide Sheet, dated 1/28/2025, the spreadsheet indicated residents on regular diet (no restrictions) would include the following foods in the tray:

- Chicken fajita with flour tortilla two (2) each

- Chuckwagon corn 1/2 cup (c, a household measurement)

- Steamed rice 1/2 c

- Sliced pears 1/2 c

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an observation on 1/28/2025 at 11:45 a.m., of the trayline (an area where foods are assembled from

the steamtable to the resident's plate), staff started placing the sliced pears on the trays in all the carts. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/28/2025 at 12:00 p.m., of the trayline, a container of coleslaw was out by the steamtable without any ice that would make the coleslaw cold. Residents Affected - Some

During an observation on 1/28/2025 at 12:27 p.m. of the trayline, the coleslaw has been sitting on the steamtable top.

During a concurrent observation and interview on 1/28/2025 at 12:37 p.m. of the coleslaw with the [NAME] 1 and the District Manager (DM), observed the coleslaw temperature was at 75 F. [NAME] 1 stated she put the coleslaw out at around 12:00 p.m. DM stated the coleslaw had to be in an ice bath to keep its temperature cold.

During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview with the DM, observed the following temperature temped by the DM for foods:

- Chicken fajita 111 F.

- Chuckwagon corn 105 F.

- Steamed riced 103 F.

- Pears 68 F.

- Puree chicken fajita 100 F.

- Puree tortilla 111 F.

- Puree rice 107 F.

- Puree pears 65 F.

The DM stated the trayline lunch service lasted longer today and the food temperatures were not supposed to be where it was. The DM stated desserts should be about 30 F. The DM stated it was not a good practice for staff to put the dessert ahead of time. The DM stated although the food could be out for two (2) hours for food safety, when residents received food that were not hot or cold, they ended up being dissatisfied. The DM stated resident would not eat the food and would lose weight as a potential outcome.

During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, dated 1/22/2025, the P&P indicated, Food will be prepared by methods that conserve nutrient value, flavor and appearance. Food will be palatable, attractive, and serve at a safe and appetizing temperature. Definitions: Proper (safe and appetizing) temperature: Food should be at the appropriate temperature as determined by

the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of the facility's P&P titled, Food: Preparation, dated 1/22/2025, the P&P indicated, (13) All foods will be held appropriate temperatures, greater than 135 F (or as state regulation requires) for hot Level of Harm - Minimal harm or holding, and less than 41 F for cold food holding. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree tortilla was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) and puree corn did not hold its shape for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4).

These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 27 of 27 residents on puree diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Findings:

During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled, Diet Guide Sheet, dated 1/28/2025, the spreadsheet indicated residents on dysphagia puree diet would include the following foods in the tray:

- Pureed chicken fajita 1/2 cup (c, a household measurement)

- Pureed cream style corn 1/2 c

- Pureed steamed rice 1/2 c

- Pureed sliced pears 1/2 c

During an observation on 1/28/2025 at 12:11 p.m. of the trayline (an area where foods were assembled from

the steamtable to resident's plate), observed puree corn was watery and did not hold its shape when plated

on the plate.

During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) on 1/28/2025 at 1:34 p.m. of puree diet with the District Manager (DM) and the Dietary Supervisor (DS), the DM stated the corn did not hold its shape on the plate and the visual presentation could be affected and would not be appetizing to the residents. The DM stated the puree tortilla did not fall off the spoon-tilt test and it was too sticky. The DM stated the staff did not add sufficient liquid for the puree tortilla to be a little softer. The DS stated residents would not eat the puree food causing weight loss if the foods were not appetizing to them.

The DM stated residents could choke on puree food if it was too sticky as a potential outcome.

During a review of the facility's policy and procedure (P&P) titled, Menus, dated 1/22/2025, the P&P stated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance to established national guidelines. Menus will be developed to meet the criteria through the use of the approved menu planning guide. (3) Menu cycles will include standardized recipes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During a review of the facility's P&P titled, Standardized Recipes, dated 1/22/2025, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's recipe titled, Tortilla Flour (6 inches)- 1 each, undated, the recipe indicated, (1) For pureed: measure out desired # of servings into food processor. Blend until smooth. Add liquid if Residents Affected - Some product needs thinning. Add commercial thickener if product needs thickening.

During a review of the facility's recipe titled, Corn, Creamed Style (can) 1/2 cup undated, the recipe indicated, (1) For pureed: measure out desired # of servings into food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener if product needs thickening.

During a review of the facility's P&P titled, Diet Manual, dated 1/22/2024, the P&P indicated, An approved Diet Manual will be used for menu planning for regular and therapeutic diet plans. (4) The Dinning Services Director and Registered Dietitian/Nutritionist (RDN), or other clinically qualified nutrition professional will ensure that the Diet Manual serves as a guide for ordering diets, and that the menus served will be consistent with the Diet Manual.

During a review of the facility's diet and nutrition care manual titled, Dysphagia Puree (Level 1) Diet, dated 1/22/2025, the document indicated, This diet is used only for people who have severe chewing and/or swallowing problems. All foods are pureed to stimulate a soft food bolus, eliminating the whole chewing phase. Thoroughly evaluate individuals before placing on puree diet, and periodically, re-evaluate for ability to advance to the next level of dysphagia diet. All foods must be the consistency of moist, mashed potatoes or pudding.

During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. (IDDSI, July 2019, The IDDSI Framework section).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:

1. Kitchen equipment and kitchen areas were not cleaned and sanitized.

a. Refrigerator and Freezer floors had dirt build up.

b. Vents had dust buildup

2. Preparation [NAME] 1 washed the towel cloth in the preparation sink area while the chicken was thawing

on the other sink causing water splatters to go the chicken.

3. Three (3) of four (4) light bulbs in the dry storeroom area were not covered

4. Two (2) dented cans were found with non-dented cans.

5. Twenty one of 21 resident's trays were cracked and chipped.

6. Pots and pans stacked wet.

7. Staff was wearing a bracelet during food preparation.

8. Expired food items of three (3) residents in the refrigerator

9. Residents' freezer temperature was not monitored; there was no thermometer and ice cream stored in it was not rock-solid.

These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 149 of 155 medically compromised residents who received food and ice from the kitchen.

Findings:

1.a. During an observation on [DATE REDACTED] at 8:34 a.m., of the walk-in refrigerator, observed dirt debris and dust buildup on the floor.

During an observation on [DATE REDACTED] at 8:35 a.m., observed dirt buildup on the floor in the walk-in freezer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a concurrent observation and interview on [DATE REDACTED] at 8:54 a.m., with the District Manager (DM), the DM stated there was dirt buildup in the walk-in freezer and walk in refrigerator floors. The DM stated the last Level of Harm - Minimal harm or time it was cleaned was last Thursday and it was important to maintain the cleanliness to prevent potential for actual harm cross-contamination as they have food in the dirty area. The DM stated the staff only cleaned what they see and what they do not see and needed to deep clean. Residents Affected - Some

During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezer, dated [DATE REDACTED],

the P&P indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. (10) Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.

b. During an observation on [DATE REDACTED] at 11:29 a.m., of the kitchen vents, observed four (4) of 4 vents had dust buildup.

During a concurrent observation and interview on [DATE REDACTED] at 12:12 p.m. of the kitchen vents with the Dietary Supervisor (DS) and the DM, the DS stated the maintenance staff clean the vents, but it had dust buildup.

The DS stated he was not sure as to when the last time the vent was cleaned. The DM stated it was not okay as dust could go everywhere including food and could cause cross-contamination.

During a review of the facility's P&P titled, Environment, dated [DATE REDACTED], the P&P indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. (1) The Dinning Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated,,d+[DATE REDACTED].13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph ,d+[DATE REDACTED].11 (D)(6).

2. During an initial kitchen tour observation on [DATE REDACTED] at 8:35

a.m. in the two-compartment sink area, observed staff washing white cloth in the first compartment while thawing raw chicken on the second compartment, causing the water from the first compartment cross-over

the pan of the thawing chicken in the second compartment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a concurrent observation and interview on [DATE REDACTED] at 9:06 a.m., of the two-compartment preparation sink with the DM, the DM stated there was raw chicken thawing on a pan with cold water on. The DM stated Level of Harm - Minimal harm or the first sink is used for washing vegetables and the second sink is for thawing. The DM stated they could potential for actual harm not wash a cloth in the sink because it could splatter water on the chicken being thawed and it would be cross-contamination. Residents Affected - Some

During a review of the facility's P&P titled, Food Preparation, dated [DATE REDACTED], the P&P indicated, (2) Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological and chemical contamination.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts [DATE REDACTED]-306.

3. During a concurrent observation and interview on [DATE REDACTED] at 9:19 a.m., in the storage room [ROOM NUMBER] with the DM, observed three (3) of four (4) light bulbs were not covered. The DM stated it was important to cover the light bulb because of safety and prevention of physical contamination of food.

During a review of the facility's P&P titled, Environment, dated [DATE REDACTED], the P&P indicated, All food preparation areas, food service areas will be maintained in a clean and sanitary condition.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code indicated, ,d+[DATE REDACTED].11 Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

4. During a concurrent observation and interview on [DATE REDACTED] at 9:19 a.m., in the storage room [ROOM NUMBER] with the DM, the DM stated there were two dented cans not placed in the dented can area near

the emergency supply. The DM stated it was important to separate dented cans from non-dented cans to avoid using it for residents as dented cans can release chemical and metal could go to the food for cross-contamination.

During a review of the facility's P&P titled, Receiving, dated [DATE REDACTED], the P&P indicated (4) All canned foods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor for disposal, as appropriate.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under , d+[DATE REDACTED].12, honestly presented. ,d+[DATE REDACTED].11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S,d+[DATE REDACTED].11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that,

after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. Level of Harm - Minimal harm or potential for actual harm 5. During an observation on [DATE REDACTED] at 11:37 a.m. on the trayline (area where food is assembled from the steamtable to the resident's plate), observed 21 of 21 resident's tray had cracks and chips. Residents Affected - Some

During a concurrent observation and interview on [DATE REDACTED] at 1:45 p.m., of the resident's trays with the Dietary Supervisor (DS) and the DM, the DS stated the trays had cracks and they have requested for it to get replaced however, the DS did not remember as to when the request was made. The DM stated the resident's tray metal was coming out and residents could cut themselves and could be a dignity issue. The DM stated there could be a possible growth of bacteria on the resident's tray because it was not a smooth surface. The DM stated the bacteria from the trays could contaminate the food.

During a review of the facility's P&P titled, Equipment, dated [DATE REDACTED], the P&P indicated, All foodservice equipment will be clean, sanitary, and in proper working condition.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.

6. During an observation on [DATE REDACTED] at 11:41 a.m., of the storage rack by the dish room, observed the pans were stacked wet.

During an interview on [DATE REDACTED] at 1:48 p.m. of the storage rack by the dishroom with the DS, the DS stated staff air dry the pots and pans at the end of dishmachine area before bringing it to the storage racks. The DS stated the pots and pans were stacked wet, and it was not okay as it could cause moist for bacterial growth.

During a review of the facility's P&P titled, Manual Warewashing, dated [DATE REDACTED], the P&P indicated, (3) All service ware and cookware will be air dried prior to storage.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

7. During an observation on [DATE REDACTED] at 11:32 a.m. of the cooking process, observed [NAME] 1 wearing a bracelet while cooking.

During a concurrent observation and interview on [DATE REDACTED] at 12:01 p.m., of the trayline with the DS, the DS stated [NAME] 1 was wearing bracelet and it was not okay as she could drop it on the food and it is a hazard

in the kitchen. The DS stated it could be physical contamination to food so he would ask [NAME] 1 to remove it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a review of the facility's P&P titled, Staff Attire, dated [DATE REDACTED], the P&P indicated, All employees wear approved attire for the performance of their duties. (5) Hand jewelry will be limited to a plain band. Arm Level of Harm - Minimal harm or jewelry and dangling jewelry is not permitted. potential for actual harm

A review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated ,d+[DATE REDACTED].11 Prohibition. Except Residents Affected - Some for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

8. During a concurrent observation and interview on [DATE REDACTED] at 3:41 p.m. of the Residents' refrigerator in Station one (1) with Registered Nurse 1 (RN 1), observed three (3) plastic of food dated [DATE REDACTED]. RN 1 stated

they needed to throw expired foods as they only needed to keep the food for 24 hours. RN 1 stated there were three residents' foods that were passed its expiration dates and needed to be thrown away. RN 1 stated residents could have nausea, vomiting and diarrhea upon consumption of expired food.

During a review of the facility's P&P titled, Food: Preparation, dated [DATE REDACTED], the P&P indicated, (17) All refrigerated, ready-to-eat TCS prepared foods that are to be held for more than 24 hours at a room temperature of 41 F or less, will be labeled and dated with a prepared date, (Day 1) or a use by date.

During a review of Food Code 2022, dated [DATE REDACTED], the Food Code 2022 indicated, ,d+[DATE REDACTED].17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

9. During an observation and interview on [DATE REDACTED] at 3:47 p.m., of Residents' refrigerator in Station 1 with RN 1, RN 1 stated they were not monitoring the temperature of the freezer as there was no thermometer in it. RN 1 stated the chocolate ice creams stored in the freezer were no rock solid. RN 1 stated it was important to monitor freezer temperature to ensure the product was not spoiled. RN 1 stated the possible outcome from eating expired food were change of condition for residents for nausea, vomiting and diarrhea.

During a review of the facility's P&P titled, Refrigerator and Freezer, last reviewed [DATE REDACTED], the P&P indicated, (1) Acceptable temperature ranges are 35 degrees Fahrenheit ( F, a scale of temperature) to 40 F for refrigerators and less than 0 F for freezers. (2) Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.

During a review of the facility's P&P titled, Food: Safe Handling for Foods from Visitors, dated [DATE REDACTED], the P&P indicated, (5) Refrigerator/freezers for storage of food brought in by visitors will properly be maintained, and:

- Equipped with thermometers

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 - Have temperature monitored daily for refrigeration less than or equal to 41 F and freezer less than or equal to 0 F. Level of Harm - Minimal harm or potential for actual harm During a review of Food Code 2022, dated [DATE REDACTED], the Food Code indicated ,d+[DATE REDACTED].112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a Residents Affected - Some TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Some when:

a. The trash in the handwashing area was not lined with plastic

b. The dumpster's (large trash container designed to be emptied into a truck) surroundings had liquid, food juices spills and trash on the ground and the dumpster was not fully covered.

These failures had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 149 of 156 facility residents.

Findings:

a. During an observation on 1/28/2025 at 11:30 a.m., in handwashing area, the trash bin was not lined with plastic.

During a concurrent observation and interview on 1/29/2025 at 12:44 p.m. with the Dietary Supervisor (DS),

the DS stated the trash can by the handwashing machine was not lined and they must put plastic in it as it was not sanitary and for infection control.

b. During a concurrent observation and interview on 1/29/2025 at 12:40 p.m. of the dumpster area with the Dietary Supervisor (DS), the DS stated the garbage floor needed to be sprayed and clean as there was liquid spills and dumpster container had sticky dirt. The DS stated the dirt was brown debris and could be anything, food or something else. The DS stated it was not acceptable as it could attract rodents in the facility, and

they do not want rodents' infestation (a presence of unusually large number of insect or animal in a place to cause disease). The DS stated the floor has trash too and the cover of the dumpster had a gap not covering

the whole dumpster. The DS stated it was not acceptable for the dumpster not to be completely covered as it could attract flies, and it could spread infection.

During an interview on 1/29/2025 at 3:55 p.m. with the Maintenance Supervisor (MS), the MS stated the dumpster looked nasty and the sticky dirty could be from the food after seeing a photograph of the dumpster.

The MS stated the dumpster was open and needed to always close as it could attract odors and mosquitos.

The MS stated the surrounding areas of the dumpster must be clean as it could attract insect causing spread of infection. The MS sated the trash gets picked up everyday but sometimes the vendor does not pick up.

The MS stated this was not acceptable as it could spread infection to the residents as a potential outcome.

During a review of the facility's policy and procedure (P&P) titled, Environment, dated 1/22/2025, indicated (6) All trash will be contained, covered, leak-proof containers that prevent cross-contamination. (7) All trash will be properly disposed of in external receptables (dumpsters) and the surrounding area will be free of debris.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 During a review of the facility's P&P titled, Dispose of Garbage and Refuse, dated 1/22/2025, the P&P indicated, All garbage and refused will be collected and disposed in a safe and efficient manner. (1) The Level of Harm - Minimal harm or Dinning Services Director coordinates with the Director of Maintenance to ensure that the area surrounding potential for actual harm the exterior dumpster is maintained in a manner free of rubbish or other debris.

Residents Affected - Some During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38552

Residents Affected - Few Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards to two of two sampled residents (Resident 116 and 120) by failing to document if Resident 116's Humulin (a hypoglycemic medication/insulin-a hormone that lowers the level of sugar in the blood) and Resident 120's Lispro (a hypoglycemic medication) doses were administered or not administered.

This deficient practice had the potential to result in inaccurate documentation in the medical records regarding the residents' medication administration.

Findings:

a. During a review of Resident 116's Admission Record, the Admission Record indicated the facility originally admitted the resident on 6/30/2023 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 116's History and Physical (H&P), dated 7/3/2023, the (H&P) indicated the resident does not have decision making capacity.

During a review of Resident 116's Minimum Data Set (MDS-a resident assessment tool), dated 1/3/2025, the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated was taking hypoglycemic medications.

During a review of Resident 116's physician order, the physician order dated 7/3/2023 indicated Humulin R Injection Solution100 unit/milliliter (ml-a unit of measurement) inject as per sliding scale . subcutaneously (beneath the skin) before meals and at bedtime for DM).

During a concurrent interview and record review on 1/31/2025 at 4:46 p.m., with the Director of Nursing (DON), Resident 116's Medication Administration Record (MAR) 1/2025 was reviewed. The MAR indicated missing documentation for Humulin at 6:30 a.m. on 1/8/2025 and 1/11/2025. The DON stated documentation is intended for monitoring if medications are administered as ordered for them to know of the resident's blood sugar levels. The DON stated the staff can do late documentation as soon as they remember. The DON stated the resident would have a potential for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) if documentation is not being done. The DON stated when the licensed nurses do not document the medication administration, then it (medication administration) is not done.

b. During a review of Resident 120's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/22/2024 with diagnoses including type 2 DM, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and HTN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a review of Resident 120's H&P, dated 8/24/2024, the H&P indicated the resident has the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 120's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated Resident 120 was taking hypoglycemic Residents Affected - Few medications.

During a review of Resident 120's physician order dated 12/3/2024, the physician order indicated Insulin Lispro Injection Solution 100 unit/ml inject as per sliding scale . subcutaneously before meals and at bedtime for DM to inject within 15 minutes before meal or with first bite of the meal.

During a concurrent interview and record review on 1/31/2025 at 4:46 p.m., with the DON, Resident 120's [DATE REDACTED]/2025 was reviewed. The MAR indicated missing documentation for insulin lispro on: 1/4/2025 at 11:30 a.m.; 1/8/2025 at 11:30 a.m.; 1/12/2025 at 4:30 p.m. and 9:00 p.m.; 1/15/2025 4:30 p.m. and 9:00 p.m. ; and 1/20/2025 at 11:30 a.m. The DON stated documentation is intended for monitoring if medications are administered as ordered for them to know of the resident's blood sugar levels. The DON stated the staff can do late documentation as soon as they remember. The DON stated the resident would have a potential for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) if documentation is not being done. The DON stated when the licensed nurses do not document the medication administration, then it (medication administration) is not done.

During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed and approved on 1/22/2025, the P&P indicated services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between

the interdisciplinary team regarding the resident's condition and response to care . The following information is to be documented in the resident's medical record: a. objective observations; b. medications administered . 7. Documentation of procedures and treatments will include care-specific details, including a. date and time

the procedure/treatment was provided . e. whether the resident refused the procedure/treatment; notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and Residents Affected - Few control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to:

1. Ensure resident urinals were labeled with a resident identifier for one of two sampled residents (Resident 357) reviewed during the Urinary Tract Infection (UTI- an infection in the bladder/urinary tract) care area.

2. Ensure resident's hand-held nebulizer (HHN - a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing was placed inside the plastic storage after use for one (1) out of two (2) sampled residents (Resident 21) reviewed under the Respiratory care area.

This deficient practice had a potential to spread infections and illnesses among residents.

Findings:

a. During a review of Resident 357's Admission Record, the Admission Record indicated the facility admitted

the resident on 3/11/2021 and readmitted the resident on 1/27/2025 with diagnoses that included UTI, benign prostatic hyperplasia (BPH - enlargement of the prostate gland that may result in urinary retention), and depression (persistent feelings of sadness and loss of interest that can interfere with daily living).

During a review of Resident 357's History and Physical (H&P), dated 1/27/2025, the H&P indicated the resident was alert to person, place, and time; had fatigue and weakness; and had an unsteady gait.

During a review of Resident 357's Care Plan (CP) titled, Resident experiences or is at risk for urinary retention related to BPH, initiated 1/28/2025, indicated to facilitate easy access to the bathroom, urinal, or commode with assistance.

During an observation on 1/28/2025 at 9:25 a.m., Resident 357 was observed lying in bed, awake and alert.

A used urinal was on the resident's bedside rolling table. Resident 357 stated the staff needed to collect a sample from the urinal. The urinal was not labeled with a resident identifier.

During a concurrent observation and interview on 1/28/2025 at 9:30 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 entered Resident 357's room and stated urinals should be labeled with a resident identifier for infection control reasons. LVN 4 stated the urinal on Resident 357's bedside table was not labeled, but it should have been. LVN 4 stated there were two residents in the room and it was important to label the urinals to ensure the urinal was not used by more than one resident. LVN 4 stated there was a potential for

the spread of infection from one resident to another if the same urinal was used for two residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/31/2025 at 8:30 a.m., with the Director of Staff Development (DSD), the DSD stated

the facility staff label all urinals with the resident room and bed number to identify the urinal is for one Level of Harm - Minimal harm or resident. The DSD stated urinals are for single resident use because the urinal may have bacteria on it with potential for actual harm the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) if used by another Residents Affected - Few resident.

During a concurrent interview and record review on 1/31/2025 at 9:30 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedure regarding infection control and personal property.

The DON stated urinals are labeled with the resident room and bed number. The DON stated urinals are labeled so they are not interchanged between residents for infection control. The DON stated if a resident had an infection and used a urinal there was a potential it may transfer to another resident if a urinal was shared between the residents. The DON stated a urinal is like personal property and should be labeled. The DON stated the facility policy was not followed when Resident 357's urinal was not labeled.

During a review of the facility P&P titled, Infection Prevention and Control Program, last reviewed 1/22/2025,

the P&P indicated an infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Important facets of infection prevention include: instituting measures to avoid complications or dissemination, and education staff and ensuring that they adhere to proper techniques and procedures.

During a review of the facility policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed 1/22/2025, the P&P indicated resident care equipment, including reusable items will be cleaned and disinfected. Reusable single resident-use items are cleaned/disinfected between uses by single resident (e.g. urinals).

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b.During a review of Resident 21's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/6/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), and generalized muscle weakness.

During a review of Resident 21's History and Physical (H&P) dated 12/5/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 21's MDS, dated [DATE REDACTED], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 21's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/26/2025:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Budesonide Inhalation Suspension (a steroid [a class of drugs that can reduce inflammation in the body] that decreases inflammation in the airways in the lungs which improves airflow and makes breathing easier) Level of Harm - Minimal harm or 1 MG/2ML one (1) application inhale orally via nebulizer two times a day for shortness of breath for seven potential for actual harm days.

Residents Affected - Few During a concurrent observation and interview on 1/28/2025 at 9:30 a.m., while inside Resident 21's room with Registered Nurse 2 (RN 2), RN 2 verified Resident 21's HHN set up including the mask, medicine cup, and tubing was just laying on top of the resident's belongings at the bedside table and not placed inside a plastic storage bag. RN 2 stated the licensed nurse should place the HHN set up inside the plastic storage bag at the bedside after use to prevent the set up to be contaminated and cause infection to the resident. RN 2 stated Resident 21's HHN set up should have been placed inside the plastic storage bag to ensure the set up did not get contaminated and placed Resident 2 at risk for acquiring infection due to a contaminated tubing.

During an interview on 1/30/2025 at 4:14 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the whole HHN set up are supposed to be placed inside the plastic storage bag after providing HHN treatment to the residents to prevent contamination of the set up. The ADON stated Resident 21's HHN set up should have placed inside the plastic storage bag after HHN treatment to prevent contamination which placed Resident 21 at risk for acquiring infection due to the contaminated tubing.

During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, last reviewed 1/25/2025, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The P&P further indicated important facets of infection and prevention include:

-Instituting measures to avoid complications or dissemination.

-Educating staff and ensuring that they adhere to proper techniques and procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of102 056113

F-F700 (Resident 145)

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 a. 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 Level of Harm - Minimal harm or stenosis (a narrowing of the spinal canal in your lower back that may cause pain or numbness in your legs), 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. Residents Affected - Some

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:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 a. Incorporate identified problem areas.

Level of Harm - Minimal harm or b. Incorporate risk and contributing factors associated with identified problems. potential for actual harm c. Build on the resident's individualized needs, strengths, preferences . Residents Affected - Some f. Reflect treatment goals, timetables, and objectives in measurable outcomes .

The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of resident's are ongoing and care plans arc reviewed and revised as information about the resident and the resident 's condition change.

43455

b. During a review of Resident 141's Admission Record (a document containing demographic and diagnostic information,) dated 1/30/2025, the Admission Record indicated Resident 141 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including Afib.

During a review of Resident 141's Order Summary Report, dated 8/22/24, the report indicated Resident 141 was prescribed Pradaxa 150 milligram ([mg] - a unit of measure of mass) one tablet by mouth every 12 hours for Afib., starting 12/18/2024.

During a review of Resident 141's Care Plan, initiated 12/31/2024, the Care Plan indicated: Resident is at risk for injury or complications related to the use of anticoagulation therapy medication Pradaxa. Observe for active bleeding, i.e. hematuria, bruising, guaiac+ (bloody) stool, nose bleeds, bleeding gums, etc.

During a review of Resident 141's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for January 2025, the MAR indicated Resident 141 was prescribed Pradaxa 150 mg one tablet by mouth every 12 hours for Afib., at 9 a.m. and 9 p.m. The MAR did not contain documentation for the monitoring of side effects of Pradaxa between 1/1/2025 and 1/30/2025.

During a concurrent record review and interview on 1/30/2025 at 10:08 a.m., with the DON, the DON stated that Resident 141's Care Plan dated 12/31/2024 indicated Resident 141 was at risk of complications from Pradaxa, and to monitor for active bleeding. The DON stated monitoring for bleeding would be documented

on the MAR, and that the DON was unable to locate documentation for monitoring for bleeding related to the use of Pradaxa for Resident 141 between 1/1/2025 and 1/30/2025. The DON stated that monitoring for bleeding with Pradaxa use was important to ensure Resident 141 does not have bleeding that was unnoticed, which may harm the resident and require hospitalization . The DON stated the facility failed to implement the Care Plan to accurately reflect the needs of Resident 141 and ensure to maintain the highest level of functionality and quality of life, with measurable goals and outcomes for Afib with the use of Pradaxa.

The DON stated that monitoring for anticoagulation therapy with Pradaxa will be immediately implemented for Resident 141.

A review of the facility's Policy & Procedures (P&P,) titled Care Plan Comprehensive, last reviewed 1/22/2025, the P&P indicated that 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 1. Each resident's comprehensive care plan is designed to:

Level of Harm - Minimal harm or c. Build on the resident's individualized needs, strengths, preferences. potential for actual harm f. Reflect treatment goals, timetables, and objectives in measurable outcomes. Residents Affected - Some 2. The comprehensive care plan includes the following:

a. The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

A Review of the facility's P&P titled Medication Regimen Review, last reviewed 1/22/2025, the policy indicated:

5. The Medication Regimen Review involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example:

d. inadequate monitoring for adverse consequences

9. An irregularity refers to the use of medication .without adequate monitoring .and or in the presence of adverse consequences.

38552

c. During a review of Resident 147's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/29/2024 with diagnoses including nondisplaced intertrochanteric fracture (break-in bone) of the right femur (thigh bone), orthopedic aftercare (follow-up care and treatment after surgery or an injury to bones or joints), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).

During a review of Resident 147's History and Physical, dated 12/1/2024, the History and Physical indicated

the resident had a plan for rehabilitation and has good rehab potential.

During a review of Resident 147's Order Summary Report, the summary report indicated the following:

- Physical Therapy (PT) - Evaluation and Treatment as recommended, dated 11/29/2024.

- PT clarification of treatment for therapeutic exercises, neuromuscular reeducation, therapeutic activities, and gait training daily for five (5) days per week for 30 days, dated 11/30/2024.

- Continue PT treatment for therapeutic exercises, neuromuscular reeducation, therapeutic activities, gait training daily for 5 days per week for 30 days, dated 12/30/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of Resident 147's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident had an impairment on one Level of Harm - Minimal harm or side on the lower extremity that interfered with daily functions or placed the resident at risk of injury. The potential for actual harm MDS indicated the resident required maximal assistance with the ability to roll left and right, sit to lying, lying to sitting on one side of bed, sit to stand, chair/bed-to-chair transfer. Residents Affected - Some

During an observation on 1/30/2025 at 3:10 p.m., at Resident 147's bedside, with Physical Therapist 1 (PT 1), PT 1 asked the resident if they could change the sheet so they could roll her to the right, but the resident refused to move. PT 1 asked the resident to change her position from lying to sitting on the side of the bed. PT 1 assisted the resident to sitting in the side of bed position. Resident 147 stated she wants to lie back down in the bed. Resident 147 refused to continued physical therapy treatment.

During a concurrent interview and record review on 1/31/2025 at 2:32 p.m., with PT 1, Resident 147's Missed Visit Details, were reviewed and indicated the following:

- 12/12/2024 -refused treatment even with max encouragement.

- 12/13/2024 - refused treatment family present and unable to encourage resident to participate in therapy.

- 12/16/2024 - refused treatment.

- 12/17/2024 - refused treatment.

- 1/10/2025, refused treatment multiple attempts and max encouragement.

PT 1 stated Resident 147's missed visit details were reported to the Director of Rehabilitation (DOR) and informed that they were having issues with the resident. PT 1 stated the DOR will then involve social services and the interdisciplinary team members.

During a concurrent interview and record review on 1/31/2025 at 1:55 p.m., with the Social Services Assistant 1 (SSA 1), Resident 147's Social Services Assessment and Documentation dated 12/3/2024 was reviewed. SSA 1 stated they discussed with the rehab team the resident's progress in the minutes, but it is not documented in the resident's progress notes. SSA 1 stated 12/3/2024 was the last contact she had with

the resident's RP.

During an interview on 1/31/2025 at 2:42 p.m., PT 1 stated Resident 86 required maximum encouragement including talking to the resident and explaining what they are going to do; approach more than once or keep trying; explain to the resident while providing the care/treatment; continually encourage resident to participate; try different approaches such as with rolling left and right and bed they can ask the resident would they like their sheet changed. PT 1 stated the potential outcome for the resident for multiple missed visit details would be stiffness, atrophy of the legs, loss of muscle strength, loss of sitting balance and tolerance, and at risk for skin breakdown if the resident is in bed all the time. PT 1 stated the care plan should be revised to reflect the updated goal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During an interview on 1/31/2025 at 4:08 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated she was part of

the IDT meeting on 12/10/2024 and 12/17/2024 and had discussed Resident 86's refusal to participate in Level of Harm - Minimal harm or physical therapy treatments. MDSN 1 stated they should have developed the care plan when the resident potential for actual harm had multiple refusals. MDSN 1 stated this was not done and should have been documented in the IDT notes to reflect that it was discussed and addressed. Residents Affected - Some

During an interview on 1/31/2025 at 4:55 p.m., with the DON, the DON stated she was made aware that Resident 147 had episodes of refusals and participating with rehab when the son was here. The DON stated

the IDT should have identified this and should have discussed with the son and should have been written.

The DON stated moving forward they would need to update and document and prove that they tried their due diligence that resident refused. The DON stated there is a potential for the resident's continuous refusal to result in a decline in their functional level.

During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed 1/22/2035, 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 for each resident. Each resident ' s comprehensive care plan is designed to:

a. Incorporate identified problem areas.

b. Incorporate risk and contributing factors associated with identified problems.

c. Build on the resident's individualized needs, strengths, preferences .

f. Reflect treatment goals, timetables, and objectives in measurable outcomes .

The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of resident's are ongoing, and care plans are reviewed and revised as information about the resident and the resident 's condition change.

d. During a review of Resident 86's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/27/2021 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline

in mental abilities).

During a review of Resident 86's History and Physical, dated 8/31/2023, the History and Physical indicated

the resident does not have the capacity to understand and make decisions.

During a review of Resident 86's Braden Scale for Predicting Pressure Sore (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) Risk, dated 9/19/2024, indicated the resident had a mild risk for pressure sore development.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of Resident 86's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to understand others and had the ability to make self understood. The MDS indicated the resident required Level of Harm - Minimal harm or moderate assistance with rolling left and right on the bed and required maximal assistance with lying to potential for actual harm sitting on the side of bed and with no back support. The MDS indicated the resident used a pressure reducing device for bed. Residents Affected - Some

During an observation on 1/28/2025 at 9:21 a.m., while at Resident 86's bedside, Resident 86 was lying in bed with LALM settings at 400 pounds (lbs - a unit of measurement).

During a concurrent observation and interview on 1/31/2025 at 11:45 a.m., while at Resident 86's bedside, Resident 86 was lying in bed with LALM settings at 350 lbs. with the red light on low pressure. Certified Nursing Assistant 4 (CNA 4) stated the resident's LALM will alarm every 15 minutes (min-a unit of measurement) so he sets the LALM settings beyond the resident's weight. CNA 4 stated he can adjust the weight settings up or down, usually sets it at maximum, but set it at 350 lbs today. CNA 4 stated if he sets it at 150 lbs of the resident's weight the LALM will alarm. CNA 4 stated this has been going on for about 3 months now and has informed the previous charge nurse but has not informed Licensed Vocational Nurse 5 (LVN 5) today. CNA 4 stated yes CNAs can adjust the LALM settings.

During an interview on 1/31/2025 at 11:53 a.m., with LVN 5, LVN 5 stated he was not aware of Resident 86's LALM not working. LVN 5 stated only the treatment nurse can adjust the resident's mattress settings.

During a concurrent interview and record review on 1/31/2025 at 12 p.m. with Registered Nurse 2 (RN 2), Resident 86's physician orders was reviewed. RN 2 stated there was no order for the use of the LALM. RN 2 stated there should be an order for the use of the LALM as part of the monitoring and treatment for the resident.

During a concurrent interview and record review on 1/31/2025 at 12:03 p.m. with RN 2, Resident 86's care plans were reviewed. RN 2 stated there was no care plan developed for the use of the LALM.

During an interview on 1/31/2025 at 4:41 p.m., with the DON, the DON stated LALM are for residents who have multiple pressure ulcers or have a high risk for development of pressure ulcers. All residents have a pressure reducing mattress which is pressure reliving and can have it to help to prevent the resident from developing pressure ulcers. The DON stated the use of LALM needs to have settings in place and the treatment nurse would place a sticker on the machine indicating what the setting is, this way everyone would know. The DON stated there would be an order and it would be monitored in the electronic medical administration record. The DON stated CNAs cannot manipulate the LALM settings and they should report

the issue to their charge nurse or treatment nurse. The DON stated the LALM is for prevention and a care plan should be developed. The DON stated the resident could potentially be at risk for a pressure ulcer when care plan interventions are not implemented correctly.

During a review of the facility 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 for each resident. Each resident's comprehensive care plan is designed to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 a. Incorporate identified problem areas.

Level of Harm - Minimal harm or b. Incorporate risk and contributing factors associated with identified problems. potential for actual harm c. Build on the resident's individualized needs, strengths, preferences . Residents Affected - Some f. Reflect treatment goals, timetables, and objectives in measurable outcomes .

The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of resident's are ongoing and care plans arc reviewed and revised as information about the resident and the resident 's condition change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 44244

Residents Affected - Few Based on interview and record review the facility failed to ensure resident comprehensive care plans (CP - a written course of action that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) regarding smoking were updated after a change of condition for one of five sampled residents (Resident 62) reviewed under the Accidents care area.

This deficient practice had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives regarding the resident's care needs.

Findings:

During a review of Resident 62's Admission Record, the Admission Record indicated the facility admitted the resident on 5/27/2019 and readmitted the resident on 1/4/2025 with diagnoses that included seizures (abnormal electrical activity in the brain), difficulty walking, and muscle weakness.

During a review of Resident 62's Minimum Data Set (MDS - resident assessment tool), dated 1/9/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required supervision or touching assistance with oral hygiene, toileting, dressing, and personal hygiene. The MDS indicated the resident had one fall since admission or readmission.

During a review of Resident 62's History and Physical (H&P), undated, the H&P indicated the resident ambulated with walker and had the capacity to understand and make decisions.

During a review of Resident 62's Change of Condition (COC) Evaluation, dated 1/5/2025, the COC indicated

the resident fell and was found on his right side on the floor of the outside patio.

During a review of Resident 62's Smoking Evaluation, dated 1/6/2025, the evaluation indicated the resident required supervision while smoking due to being a fall risk.

During a review of Resident 62's Care Plan (CP) titled, Patient may smoke independently per smoking assessment ., initiated on 1/7/2025 and last revised on 1/28/2025, the CP indicated a goal that the resident would smoke safely. The CP indicated to reassess the resident's ability to smoke independently with any change of condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 During a concurrent interview and record review, on 1/28/2025, at 8:45 a.m., with the Assistant Director of Nursing (ADON), Resident 62's CPs and Smoking Evaluation, dated 1/6/2025, were reviewed. The ADON Level of Harm - Minimal harm or stated CPs are a tool used by all departments to know the plan of care for a resident. The ADON stated CPs potential for actual harm are developed at admission and when a resident has a change of condition, like a fall. The ADON stated Resident 62 had a fall on the patio and a smoking evaluation was completed that indicated the resident Residents Affected - Few should be supervised while smoking. The ADON stated Resident 62's CP regarding smoking indicated the resident may smoke independently. The ADON stated Resident 62's smoking CP was not updated to indicate the resident required supervision while smoking, but it should have been. The ADON stated when Resident 62's CP was not updated and revised it could have resulted in the resident not being supervised while smoking and potentially leading to injury from falls and burns.

During a concurrent interview and record review, on 1/31/2025, at 9:30 a.m., with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled Care Plan Comprehensive, last reviewed 1/22/2025, and Smoking, last reviewed 1/22/2025, were reviewed. The DON stated CPs are followed for each resident to deliver the right resident centered interventions. The DON stated a fall is a change of condition and Resident 62's smoking CP should have been updated and revised, but it was not. The DON stated when Resident 62's smoking CP was not updated and revised there was a potential that the resident would not be supervised resulting in an incident. The DON stated the facility P&Ps were not followed.

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. Each resident ' s comprehensive care plan is designed to:

a. Incorporate identified problem areas.

b. Incorporate risk and contributing factors associated with identified problems.

c. Build on the resident's individualized needs, strengths, preferences .

h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels .

Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes.

The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of resident's are ongoing and care plans arc reviewed and revised as information about the resident and the resident 's condition change. The Interdisciplinary Team is responsible for evaluation and updating of care plans:

a. When there has been a significant change in the resident' s condition .

c. When the resident has been readmitted to the facility from a hospital stay.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 During a review of the facility P&P titled, Smoking, last reviewed 1/22/2025, the P&P indicated the purpose of

the policy was to provide a safe environment for residents, staff, and visitors. Licensed Nurse will evaluate Level of Harm - Minimal harm or resident's who express a desire to smoke upon admission, quarterly, annually, significant change of potential for actual harm condition, as needed, and present it to the Interdisciplinary Team (IDT) for review. As identified by the Smoking Evaluation, residents who require assistance and / or monitoring for smoking safety are not allowed Residents Affected - Few to smoke unaccompanied. The IDT will develop an individualized plan for required supervision for residents who smoke. This is documented on the Resident Smoking Evaluation and the Resident's Plan of Care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility failed to provide care in accordance with professional Residents Affected - Some standards for three (3) of three (3) sampled residents (Resident 51, 137, and 129) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites.

The deficient practice increased the risk that Residents 51,137, and 129 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross Reference

F-F760

Findings:

a. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 - 12/6/2024: INSULIN LISPRO MUV 100UNIT/1ML VIAL Inject subcutaneously before meals and at bedtime for DM inject within 15 mins before meal or with first bite of meal. Inject as per sliding scale: if 140 - 199 = 1; Level of Harm - Minimal harm or < 70 and conscious glucogel1pack or 4 oz juice, if unconscious, glucagon IM one time and call MD; 200 - potential for actual harm 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 400 = 5. If blood sugar is greater than (> - a unit of measurement) 400 mg per deciliter (dl - a unit of measurement) = give 5 units and call MD. Residents Affected - Some

During a concurrent interview and record review on 1/30/2025 at 11:15 a.m., reviewed Resident 51's Order Summary Report, Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) Location of Administration Report for 12/2024 and 1/2025 with Licensed Vocational Nurse 2 (LVN 2), LVN 2 verified Resident 51 had a physician's order for insulin lispro and insulin glargine and were administered as follows:

- Insulin glargine-yfgn subcutaneous solution pen-injector 100 unit/ml

12/05/24 9:30 p.m. subcutaneously Abdomen - LUQ

12/06/24 9:27 p.m. subcutaneously Abdomen - LUQ

12/12/24 9:13 p.m. subcutaneously Abdomen - LUQ

12/13/24 9:23 p.m. subcutaneously Abdomen - LUQ

12/19/24 10:08 p.m. subcutaneously Arm - left

12/20/24 8:59 p.m. subcutaneously Arm - left

12/21/24 9:21 p.m. subcutaneously Abdomen - RLQ

12/22/24 9:50p.m. subcutaneously Abdomen - RLQ

12/26/24 9:24 p.m. subcutaneously Abdomen - LUQ

12/27/24 9:34 p.m. subcutaneously Abdomen - LUQ

1/16/25 9:00 p.m. subcutaneously Abdomen - LUQ

1/17/25 10:00 p.m. subcutaneously Abdomen - LUQ

1/18/25 8:23 p.m. subcutaneously Abdomen - LUQ

1/19/25 8:56 p.m. subcutaneously Abdomen - RLQ

1/20/25 9:37 p.m. subcutaneously Abdomen - RLQ

1/21/25 9:09 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

1/22/25 9:43 p.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 - Insulin lispro MUV 100 unit/ml vial:

Level of Harm - Minimal harm or 12/06/24 11:28 a.m. subcutaneously Arm - left potential for actual harm 12/07/24 11:26 a.m. subcutaneously Arm - left Residents Affected - Some LVN 2 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines. LVN 2 verified Resident 51's MAR indicated the insulin administration sites were not rotated. LVN 2 stated 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.

During an interview on 1/30/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated 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 Resident 51's insulin administration site should have been rotated as it placed the resident at risk for pain bruising, lipodystrophy, and amyloidosis.

During a review of the facility provided manufacturer's guideline on Lantus (insulin glargine, last revised on 6/2023, the manufacturer's guideline indicate to administer Lantus SQ into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into the areas of lipodystrophy or localized cutaneous amyloidosis.

During a review of the facility provided manufacturer's guideline on, Insulin Lispro Kwikpen, last reviewed on 1/25/2025, the manufacturer's guideline indicated to change or rotate injection sites within the area with each dose to reduce the risk of getting lipodystrophy (pits in ski or thickened skin) and localized cutaneous amyloidosis 9skin with lumps) at the injection sites.

- Do not use the exact same spot for each injection.

- 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.

During a review of the facility's policy and procedure (P&P) tilted, Insulin Administration, last reviewed 1/25/2025, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 b. During a review of Resident 137's Admission Record, the Admission Record indicated the facility originally admitted Resident 137 on 5/21/2024 and readmitted the resident on 1/9/2025, with diagnoses including Level of Harm - Minimal harm or congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, potential for actual harm sometimes resulting in leg swelling), type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness. Residents Affected - Some

During a review of Resident 137's MDS dated [DATE REDACTED], the MDS indicated Resident 137 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required 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 137 received insulin.

During a review of Resident 137's History and Physical (H&P) dated 1/12/2025, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

During a review of Resident 137's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:

- 12/1/2024 to 12/10/2025; 12/10/2024 to 1/9/2025: Insulin lispro (a short acting insulin) injection solution inject subcutaneously before meals and at bedtime for DM 2 to inject 15 minutes before meals or with first bite of the meal. Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on

the blood sugar level before the meal): if 71 - 150 = 0 ; less than (< - a unit of measurement) 70 if patient is conscious, give four (4) ounces (oz - a unit of measurement) of juice. If unconscious, give glucagon (a natural hormone the body makes which prevents the blood sugar from dropping too low) 1 milligram (mg - a unit of measurement) intramuscularly (IM - into the muscle tissue) one time. Notify physician (MD); 151 - 200 = 1 unit; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 -400 = 6; above 401 = 8.

- 1/9/2025: Insulin lispro injection solution inject subcutaneously before meals and at bedtime for DM 2. Inject as per sliding scale: if 151 - 200 = 1; if blood sugar is < 70 and conscious give 4 oz of juice. If unconscious give glucagon 1mg IM one time and notify MD; 201 - 250 = 2; 251 - 300 = 3; 301 - 350 = 4; 351 - 400 = 6 if blood sugar above 400, give 8 units and notify MD for DM 2.

- 9/6/2024 to 12/1/2024: Insulin glargine (Lantus - a long-acting insulin) subcutaneous solution 100 unit per ml (unit/ml - a unit of measurement) inject 50 units subcutaneously two times a day for DM 2.

- 1/9/2025: Lantus solostar subcutaneous solution pen-injector 100 unit/ml. inject 40 units subcutaneously two times a day for DM 2.

During a concurrent interview and record review on 1/30/2025 at 11:00 a.m., reviewed Resident 137's Order Summary Report, Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) Location of Administration Report for 12/2024 and 1/2025 with Licensed Vocational Nurse 2 (LVN 2), LVN 2 verified Resident 137 had a physician's order for insulin lispro and Lantus and were administered as follows:

- Insulin lispro injection solution:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/02/24 9:02 p.m. subcutaneously Arm - right

Level of Harm - Minimal harm or 12/03/24 6:06 a.m. subcutaneously Arm - right potential for actual harm 12/04/24 5:07 p.m. subcutaneously Abdomen - left upper quadrant (LUQ) Residents Affected - Some 12/04/24 9:14 p.m. subcutaneously Abdomen - LUQ

12/11/24 12:22 p.m. subcutaneously Arm - left

12/11/24 6:06 p.m. subcutaneously Arm - left

12/11/24 9:11 p.m. subcutaneously Arm - right

12/12/24 6:11 a.m. subcutaneously Arm - right

12/14/24 8:24 p.m. subcutaneously Abdomen - LUQ

12/15/24 5:26 p.m. subcutaneously Abdomen - LUQ

12/18/24 11:46 a.m. subcutaneously Abdomen - right lower quadrant (RLQ)

12/18/24 4:30 p.m. subcutaneously Abdomen - RLQ

1/22/25 4:36 p.m. subcutaneously Arm - right

1/22/25 9:22 p.m. subcutaneously Arm - right

1/23/25 5:59 a.m. subcutaneously Arm - left

1/23/25 11:50 a.m. subcutaneously Arm - left

1/24/25 6:16 a.m. subcutaneously Arm - left

- Lantus solostar subcutaneous solution pen-injector 100 unit/ml

1/19/25 10:47 a.m. subcutaneously Abdomen - RLQ

1/19/25 9:12 p.m. subcutaneously Abdomen - RLQ

12/18/24 9:00 p.m. subcutaneously Abdomen - LUQ

12/19/24 9:33 p.m. subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 LVN 2 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines. LVN 2 verified Resident 137's MAR indicated the insulin administration sites were not rotated. Level of Harm - Minimal harm or LVN 2 stated Resident 137's insulin administration sites should have been rotated per manufacturer's potential for actual harm guidelines and standards of practice to prevent pain, redness, irritation, and bumps or lumps on the resident's skin. Residents Affected - Some

During an interview on 1/30/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated 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 Resident 137's insulin administration site should have been rotated as it placed the resident at risk for pain bruising, lipodystrophy, and amyloidosis.

During a review of the facility provided manufacturer's guideline on Lantus (insulin glargine, last revised on 6/2023, the manufacturer's guideline indicate to administer Lantus SQ into the abdominal area, thigh, or deltoid, and rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into the areas of lipodystrophy or localized cutaneous amyloidosis.

During a review of the facility provided manufacturer's guideline on, Insulin Lispro Kwikpen, last reviewed on 1/25/2025, the manufacturer's guideline indicated to change or rotate injection sites within the area with each dose to reduce the risk of getting lipodystrophy (pits in ski or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

- Do not use the exact same spot for each injection.

- 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.

During a review of the facility's policy and procedure (P&P) tilted, Insulin Administration, last reviewed 1/25/2025, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated:

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

43455

c. During a review of Resident 129's Admission Record dated 1/30/2025, the Admission Record indicated the resident was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including DM2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a review of Resident 129's Order Summary Report, dated 1/30/2025, the Order Summary Report indicated Resident 129 was prescribed Regular (short-acting insulin) insulin to inject per sliding scale (insulin Level of Harm - Minimal harm or dosing plan whereby the amount of insulin administered depends on the resident's blood sugar level,) SQ potential for actual harm before meals and at bedtime related to DM2, starting 4/15/2024.

Residents Affected - Some During a review of Resident 129's MAR for January 2025, the MAR indicated Resident 129 was prescribed Regular insulin to inject per sliding scale SQ before meals and at bedtime related to DM2, at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9 p.m.

During the same review, the MAR indicated Regular Insulin was administered SQ by the following licensed nurses, on the following days, times, and sites:

1/12/25 two (2) un at 11:30 a.m. on left arm by LVN 6

1/12/25 two (2) un at 4:30 p.m. on left arm by LVN 7

1/12/25 two (2) un at 9 p.m. on left arm by LVN 7

1/16/25 two (2) un at 11:30 a.m. on left arm by LVN 6

1/16/25 two (2) un at 9 p.m. on left arm by LVN 8

During a concurrent interview and record review on 1/30/2025 at 2:18 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 129's MAR for January 2025. The DON stated that Resident 129's MAR indicated there were instances where the insulin administration sites were not rotated by several licensed nurses, as expected by facility policy, standard of practice and manufacturer guidelines. The DON stated the failure of the licensed nurses to rotate insulin administration sites could cause harm to Resident 129 by causing lipodystrophy (skin abnormalities such as lumps in the skin or thickened skin) at the repeated administration sites. The DON stated not rotating insulin administration sites was considered a significant medication error.

During a review of the facility's Policy & Procedures (P&P,) Insulin Administration, last reviewed 1/22/2025,

the P&P indicated: To provide guidelines for the safe administration of insulin to residents with diabetes.

16.b. injection sites should be rotated.

During a review of facility provided manufacturer's guide Highlights of Prescribing Information for Humulin R (brand name for Regular insulin) dated June 2023, the guide indicated to Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to provide quality of care in accordance Residents Affected - Few with professional standards of practice to meet the resident's physical, mental, psychosocial needs for one of one sampled resident (Resident 147) investigated under rehab and restorative care area by failing to:

1. Conduct the interdisciplinary team meeting (IDT-a coordinated group of experts from several different fields) with the resident's responsible party regarding the resident's refusals to participate in physical therapy treatments.

2. Inform Resident 147's physician regarding the resident's refusals to participate in physical therapy treatments.

These deficient practices had the potential to result in Resident 147's decline in mobility, strength, and overall physical function, leading to increased dependence to providers.

Findings:

During a review of Resident 147's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/29/2024 with diagnoses including nondisplaced intertrochanteric fracture (break-in bone) of right femur (thigh bone), orthopedic aftercare (follow-up care and treatment after surgery or an injury to bones or joints), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).

During a review of Resident 147's History and Physical (H&P), dated 12/1/2024, the H&P indicated the plan for rehabilitation as the resident has good rehab potential.

During a review of Resident 147's Order Summary Report, the Order Summary Report indicated the following:

- Physical Therapy (PT) - Evaluation and Treatment as recommended, dated 11/29/2024.

- PT clarification of treatment for therapeutic exercises, neuromuscular reeducation, therapeutic activities, and gait training daily for five (5) days per week for 30 days, dated 11/30/2024.

- Continue PT treatment for therapeutic exercises, neuromuscular reeducation, therapeutic activities, gait training daily for 5 days per week for 30 days, dated 12/30/2024.

During a review of Resident 147's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2024,

the MDS indicated the resident had the ability to make self understood and understand others. The MDS indicated the resident had an impairment on one side on the lower extremity that interfered with daily functions or placed the resident at risk of injury. The MDS indicated the resident required maximal assistance with the ability to roll left and right, sit to lying, lying to sitting on one side of bed, sit to stand, chair/bed-to-chair transfer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an observation on 1/30/2025 at 3:10 p.m., at Resident 147's bedside with Physical Therapist 1 (PT 1), PT 1 asked the resident if they could change the sheet; the resident could roll to her right but refused to Level of Harm - Minimal harm or move. PT 1 asked the resident to change position from lying to sitting on the side of the bed. PT 1 assisted potential for actual harm resident to sitting side of bed position. Resident 147 stated she wants to lie back to bed. Resident 147 refused to continue physical therapy treatment. Residents Affected - Few

During a concurrent interview and record review on 1/31/2025 at 2:32 p.m., with PT 1, reviewed Resident 147's Missed Visit Details, the following were reviewed:

- 12/12/2024 -refused treatment even with maximum encouragement.

- 12/13/2024 - refused treatment family at present and unable to encourage resident to participate in therapy.

- 12/16/2024 - refused treatment.

- 12/17/2024 - refused treatment.

- 1/10/2025, refused treatment multiple attempts and max encouragement.

PT 1 stated resident's missed visit details was reported to the Director of Rehabilitation (DOR) who was informed that they were having issues with the resident. PT 1 stated the DOR will then involve social services and the interdisciplinary team members.

During a concurrent interview and record review on 1/31/2025 at 1:55 p.m., with Social Services Assistant 1 (SSA 1), Resident 147's Social Services Assessment and Documentation dated 12/3/2024 was reviewed. SSA 1 stated they discussed with the rehab team the resident's progress in the minutes, but it was not documented in the resident's progress notes. SSA 1 stated 12/3/2024 was the last contact she had with the resident's RP.

During an interview on 1/31/2025 at 2:07 p.m. with Responsible Party 1 (RP 1), RP 1 stated initially Resident 147 participated in therapy. RP 1 stated he could not come every day to encourage Resident 147 with therapy. RP 1 stated he saw Resident 147 refusals to participate with therapy. RP 1 stated 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). RP 1 stated PT 1 has spoken to him about Resident 147's refusing to participate and he (RP 1) was present in some of those situations. RP 1 stated Resident 147 does not even want to open her eyes, her mind is okay, but she (Resident 147) just chose not to do the rehab exercises.

During an interview on 1/31/2025 at 2:42 p.m. with PT 1, PT 1 stated Resident 147 required maximum encouragement including talking to the resident and explaining what they are going to do; approach more than once or keep trying; explain to the resident while providing the care/treatment; continually encourage resident to participate; try different approaches such as with rolling left and right and bed they can ask the resident would they like their sheet changed. PT 1 stated the potential outcome for the resident for multiple missed visit details would be stiffness, atrophy of the legs, loss of muscle strength, loss of sitting balance and tolerance, and at risk for skin breakdown if the resident is in bed all the time. PT 1 stated the care plan should be revised to reflect the updated goal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 During an interview on 1/31/2025 at 4:08 p.m., with MDS Nurse 1 (MDSN 1), MDSN 1 stated she was part of

the IDT meeting on 12/10/2024, 12/17/2024 and had discussed Resident 147's refusal to participate in Level of Harm - Minimal harm or physical therapy treatments. MDSN 1 stated they should have developed the care plan when the resident potential for actual harm had multiple refusals. MDSN 1 stated this was not done and should have been documented in the IDT notes to reflect that it was discussed and addressed. MDSN 1 stated purpose of IDT is to ensure as a team they Residents Affected - Few are providing and ensuring interventions and goals are achieved and go home. MDSN 1 stated any changes family and MD will be notified. MDSN 1 stated the resident's MD was not notified. MDSN 1 stated the resident potential for decline such as contractures, skin injury, if the resident is not being moved and address any approaches needed for skilled rehab.

During an interview on 1/31/2025 at 4:55 p.m., with the DON, the DON stated she was made aware of Resident 147's episodes of refusals and participating with rehab. The DON stated the IDT should have identified this and should have discussed with the son and should have been documented. The DON stated moving forward they would need to update and document and prove that they tried their due diligence that resident refused. The DON stated the potential for the resident's continuous refusal would be a decline in their functional level.

During a review of the facility's policy and procedure (P&P) titled, Requesting, Refusing and/or Discontinuing Care or Treatment, last reviewed and approved on 1/22/2025, the P&P indicated if a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the interdisciplinary team (IDT) will meet with the resident/representative to:

a. determine why he or she is requesting, refusing, or discontinuing care or treatment;

b. try to address his or her concerns and discuss alternative options; and

c. discuss the potential outcomes or consequences (positive or negative) of the decision .

7. Information relating to the request, refusal, or discontinuation of treatment are documented in the resident's medical record .

9. The healthcare practitioner must be notified of refusal or treatment, in a time frame determined by the resident's condition and potential serious consequences of the request.

During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed and approved on 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 for each resident. Each resident ' s comprehensive care plan is designed to:

a. Incorporate identified problem areas.

b. Incorporate risk and contributing factors associated with identified problems.

c. Build on the resident's individualized needs, strengths, preferences .

f. Reflect treatment goals, timetables, and objectives in measurable outcomes .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of resident's are ongoing and care plans arc Level of Harm - Minimal harm or reviewed and revised as information about the resident and the resident 's condition change. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care Residents Affected - Few consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 86) investigated under pressure injury by failing to ensure Resident 86's low air loss mattress (LALM, a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) had a physician's order and care plan developed.

This deficient practice had the potential for the development and worsening of pressure injuries to Resident 86.

Findings:

During a review of Resident 86's Admission Record, the Admission Record indicated the facility admitted the resident on 8/27/2021 with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 86's History and Physical (H&P), dated 8/31/2023, the H&P indicated the resident does not have the capacity to understand and make decisions.

During a review of Resident 86's Braden Scale for Predicting Pressure Risk, dated 9/19/2024, the Braden Scale for Predicting Pressure Risk indicated the resident has mild risk for pressure ulcers.

During a review of Resident 86's Minimum Data Set (MDS-a resident assessment tool), dated 11/12/2024,

the MDS indicated the resident had the ability to understand others and had the ability to make self understood. The MDS indicated the resident required moderate assistance with rolling left and right on the bed and required maximal assistance with lying to sitting on side of bed and with no back support. The MDS indicated the resident has pressure reducing device for bed.

During an observation on 1/28/2025 at 9:21 a.m., at Resident 86's bedside, resident was lying in bed with LALM settings at 400 pounds (lbs - a unit of measurement).

During a concurrent observation and interview on 1/31/2025 at 11:45 a.m., with Certified Nursing Assistant 4 (CNA 4) at Resident 86's bedside, resident was lying in bed with LALM settings at 350 lbs with red light on low pressure. CNA 4 stated the resident's LALM will alarm every 15 minutes (min-a unit of measurement) so

he sets the LALM settings beyond the resident's weight. CNA 4 stated he can adjust the weight settings up or down, usually sets it at maximum, but set it at 350 lbs today. CNA 4 stated if he sets it at 150 lbs of the resident's weight the LALM will alarm. CNA 4 stated this has been going on for about 3 months now and has informed the previous charge nurse but has not informed Licensed Vocational Nurse 5 (LVN 5) that day. CNA 4 stated ereCNAs can adjust the LALM settings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During an interview on 1/31/2025 at 11:53 a.m., with LVN 5, LVN 5 stated he was not aware of Resident 86's LALM not working. LVN 5 stated only the treatment nurse can adjust on the resident's mattress settings. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 1/31/2025 at 12:00 p.m. with Registered Nurse 2 (RN 2), Resident 86's physician orders were reviewed. RN 2 stated there was no order for the use of the LALM. RN Residents Affected - Few 2 stated there should be an order for the use of the LALM as part of the monitoring and treatment for the resident.

During a concurrent interview and record review on 1/31/2025 at 12:03 p.m. with RN 2, Resident 86's care plans were reviewed. RN 2 stated there was no care plan developed for the use of the LALM.

During an interview on 1/31/2025 at 4:41 p.m., with the Director of Nursing (DON), the DON stated LALM are intended for residents who have multiple pressure ulcers or are at high risk for development of pressure ulcer; all residents have a pressure reducing mattress which is pressure relieving and can help prevent the resident from developing pressure ulcers. The DON stated the use of LALM needs to have settings in place and the treatment nurse would place a sticker on the machine of what would the setting be. The DON stated there would be a physician's order for the use of LALM. The DON stated CNAs cannot manipulate the LALM settings and they should report the issue to their charge nurse or treatment nurse. The DON stated the LALM is for prevention of pressure ulcers and a care plan should be developed. The DON stated the resident could potentially be at risk for pressure ulcer when care plan interventions are not implemented correctly.

During a review of the facility's policy and procedure (P&P) titled, Positioning/Transfer and Changing Resident with Airloss Mattress, last reviewed and approved on 1/22/2025, the P&P indicated the facility establishes techniques, responsibilities, and protocols for transferring, repositioning and changing of residents on an airloss mattress to ensure safety of the resident and employee. The P&P indicated low air loss mattresses are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.

During a review of the facility's P&P titled, Physician Orders, last reviewed and approved on 1/22/2025, the P&P indicated this policy will ensure that all physician orders are complete and accurate. The P&P indicated other orders will include a description complete enough to ensure clarity of the physician's plan of care. The P&P indicated the licensed nurse receiving the order will be responsible for documenting and implementing

the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record.

During a review of the facility P&P titled, Care Plan Comprehensive, last reviewed and approved on 1/22/2035, 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 for each resident. Each resident ' s comprehensive care plan is designed to:

a. Incorporate identified problem areas.

b. Incorporate risk and contributing factors associated with identified problems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 c. Build on the resident's individualized needs, strengths, preferences .

Level of Harm - Minimal harm or f. Reflect treatment goals, timetables, and objectives in measurable outcomes . potential for actual harm

The resident's comprehensive care plan is developed within seven (7) days of the completion of the Residents Affected - Few resident's comprehensive assessment (MDS). Assessments of resident's are ongoing and care plans arc reviewed and revised as information about the resident and the resident 's condition change.

During a review of the facility's operator's manual, titled Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress Replacement System with Defined Perimeter, undated, the manual indicated mute button - the audible/visible alarms turns on either when the pressure is low, or the system fails to alternate . The weight setting buttons (+) and (-) can be used to adjust the pressure of the inflated cells based on the patient's weight. As the weight increases, the pressure level indicator lights up (green) with each added level of pressure . Low pressure indicator light (red) flickers when the pressure is below the pre-defined level.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four (4) of five (5) sampled residents (Residents 94, 21, 27 and 129's) investigated under accidents by failing to:

1. Ensure there was no furniture or equipment on top of Resident 94, 21, and 27's floor mats for a long period of time.

2. Ensure Resident 129's bed was not left in the elevated/high position while unattended by staff.

These deficient practices had the potential to place Residents 94, 21, 27, and 129 at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death.

Findings:

a. During a review of Resident 94's Admission Record, the Admission Record indicated the facility originally admitted Resident 94 into the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure), and generalized muscle weakness.

During a review of Resident 94's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/10/2024, the MDS indicated Resident 94 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene; partial/moderate assistance to substantial/maximal to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 94's care plan for risk of falls initiated on 12/17/2024, the care plan included interventions to maintain a clutter free environment in the resident's room and consistent furniture arrangement to prevent falls.

During a review of Resident 94's History and Physical (H&P) dated 12/20/2024, the H&P indicated Resident 94 had the capacity to understand and make decisions.

During a review of Resident 94's Order Summary Report, the Order Summary Report included a physician's order dated 1/20/2025 to apply a non-skid mat on both sides of bed for safety.

During a review of Resident 94's fall risk evaluation form dated 12/17/2024 and 1/26/2025, the fall risk evaluations indicated Resident 94 was at risk for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent observation and interview on 1/28/2025 at 9:52 a.m., while inside Resident 94's room with Licensed Vocational Nurse 3 (LVN 3), LVN 3 verified Resident 94's overbed table was placed on top of Level of Harm - Minimal harm or the right floor mat. LVN 3 stated he was not aware that the overbed table could not be placed on top of the potential for actual harm floor mat for a long period of time. LVN 3 verified Resident 94's overbed table wheels left an indentation on

the floor affecting the integrity of the floor mat which can affect resident safety in the event a fall. LVN 3 Residents Affected - Some stated 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.

During an interview on 1/30/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the resident environment should be clutter free and there should be no equipment or furniture on top of the floor mats, as it can affect the integrity of the mat and get torn. The DON verified the manufacturer's guideline for Floor Mat 1 (FM 1) indicated to avoid placing furniture or equipment on the mat as it can cause indentations.

The DON stated Resident 94's environment should have been clutter free to include not leaving the overbed table on top of the floor mat. The DON stated the overbed table can be unstable and might fall on the resident. The DON stated Resident 94 could also hit the table when he tries to get out of bed unassisted which can lead to injury.

b. During a review of Resident 27's Admission Record, the Admission Record indicated the facility originally admitted the resident into the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN - high blood pressure), and generalized muscle weakness.

During a review of Resident 27's care plan for risk for falls initiated on 3/12/2024 and last revised on 9/16/2024, the care plan indicated floor mats on both sides of the bed and assist resident or caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement as a few of the interventions to prevent falls.

During a review of Resident 27's fall risk evaluation forms dated 9/23/2024 and 9/26/2024, the fall risk evaluations indicated Resident 27 was a risk for falls.

During a review of Resident 27's History and Physical (H&P) dated 9/26/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/6/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required setup or clean-up assistance with eating; supervision or touching assistance with oral hygiene and personal hygiene; partial/moderate assistance with upper body dressing and rolling left and right; total assistance with toileting and bathing; substantial/maximal from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent observation and interview on 1/28/2025 at 10:20 a.m., while inside Resident 27's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed Resident 27's overbed table was placed on top Level of Harm - Minimal harm or of the left floor mat. CNA 1 stated it had always been Resident 27's preference to have the overbed table on potential for actual harm top of the floor mat. CNA 1 stated she was not aware that the overbed table could not be placed on top of the floor mat for a long period of time. CNA 1 verified Resident 27s overbed table wheels were unstable when Residents Affected - Some moved. CNA 1 stated Resident 27's overbed table can fall on the resident if unstable or Resident 27 can hit

the table when she rolls out of bed by accident and get injured.

During a concurrent observation and interview on 1/28/2025 at 10:25 a.m., while inside Resident 27's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she did not know there should be no equipment or furniture placed on top of the floor mat. LVN 2 verified that the table was unstable when moved and can fall

on the resident which may lead to injury.

During an interview on 1/30/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the resident environment should be clutter free and there should be no equipment or furniture on top of the floor mats as it can affect the integrity of the mat and get torn. The DON verified the manufacturer's guideline for Floor Mat 1 (FM 1) indicated to avoid placing furniture or equipment on the mat as it can cause indentations.

The DON stated Resident 94's environment should have been clutter free to include not leaving the overbed table on top of the floor mat. The DON stated the overbed table can be unstable and might fall on the resident. The DON stated Resident 27 could also hit the table when she tries to get out of bed unassisted which can lead to injury.

c. During a review of Resident 21's Admission Record, the Admission Record indicated the facility admitted

the resident into the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), hypertension (HTN - high blood pressure), and generalized muscle weakness.

During a review of Resident 21's History and Physical (H&P) dated 12/5/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 21's fall risk evaluation forms dated 12/6/2024, the fall risk evaluations indicated Resident 27 was a risk for falls.

During a review of Resident 21's care plan for risk of falls initiated on 12/6/2024 and last revised on 1/7/2025,

the care plan included interventions to place the floor mat on the right side and maintain a clutter-free environment in the resident's room and consistent furniture arrangement to prevent falls.

During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/13/2024, the MDS indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance to total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a concurrent observation and interview on 1/28/2025 at 9:39 a.m., while inside Resident 21's room with Registered Nurse 2 (RN 2), RN 2 verified Resident 21's overbed table was placed on top of the right Level of Harm - Minimal harm or floor mat. RN 2 stated she was not sure that the table could not be placed on top of the floor mat. RN 2 potential for actual harm verified the overbed table was unstable when moved. RN 2 stated the placement of the table placed Resident 21 at risk for getting injured when the table falls on the resident or Resident 21 can hit the table Residents Affected - Some when she rolled out of bed by accident.

During an interview on 1/30/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated the resident environment should be clutter free and there should be no equipment or furniture on top of the floor mats as it can affect the integrity of mat and get torn. The DON verified the manufacturer's guideline for Floor Mat 1 (FM 1) indicated to avoid placing furniture or equipment on the mat as it can cause indentations. The DON stated Resident 94's environment should have been clutter free to include not leaving the overbed table

on top of the floor mat. The DON stated the overbed table can be unstable and might fall on the resident.

The DON stated Resident 27 could also hit the table when she tries to get out of bed unassisted which can lead to injury.

During a review of the facility provided undated manufacturer's guideline on Floor Mat 1 (FM 1), undated, the manufacturer's guideline indicated to avoid placing furniture or equipment on the mat as this may cause permanent indentations to occur.

During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs, last reviewed 1/25/2025, the P&P indicated:

- The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being

- The resident individual needs and preferences, including the need for adaptive devices and modifications to

the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.

- Adaptations may be made to the physical environment including the resident's bedroom and bathroom which include arranging furniture as the resident requests, providing the arrangement is safe, his or her roommate agrees, and space allows.

44244

d. During a review of Resident 129's Admission Record (AR), the AR indicated the facility admitted the resident into the facility on [DATE REDACTED] and readmitted the resident on 4/15/2024 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and adult failure to thrive (a state of decline due to underlying physical, mental, or psychosocial conditions).

During a review of Resident 129's Order Summary Report, the report indicated orders for fall precautions (interventions to reduce the risk of injury from falls), dated 4/16/2024.

During a review of Resident 129's History and Physical (H&P), dated 4/24/2024, the H&P indicated the resident did not have the capacity to make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a review of Resident 129's Order Summary Report, the report indicated orders for fall precautions - fall mats (a cushioned floor pad designed to help prevent injury should a person fall) on both sides of the Level of Harm - Minimal harm or bed, dated 5/2/2024. potential for actual harm

During a review of Resident 129's Minimum Data Set (MDS - resident assessment tool), dated 1/1/2025, the Residents Affected - Some MDS indicated the resident sometimes had the ability to make herself-understood and sometimes was able to understand others. The MDS further indicated the resident was dependent on staff for bathing and dressing; required substantial/maximal assistance from staff for oral and personal hygiene, toileting, and mobility in bed and for transfers.

During a review of Resident 129's Care Plan (CP) titled, Resident is at risk for falls: impaired mobility ., initiated on 2/8/2024 and last revised on 1/7/2025, the care plan indicated a goal that the resident would have no falls and to assist the resident with consistent furniture arrangement and place floor mats on both sides of the bed.

During an observation on 1/28/2025 at 10 a.m., Resident 129 was lying in bed. Resident 129 was awake and did not verbally respond. Resident 129's bed was elevated to the high position. There were no staff present

in the room and fall mats were present on both sides of the resident's bed.

During a concurrent observation and interview on 1/28/2025 at 10:10 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 entered Resident 129's room and stated the resident's bed was high. CNA 3 stated she assisted Resident 129 with breakfast and then went to another resident's room and did not lower the bed. CNA 3 stated resident 129 had fall mats but she was not sure if the resident was a risk for falls. CNA 3 stated

she would find out if the resident was a fall risk. CNA 3 exited Resident 129's room and left the resident's bed

in the high elevated position.

During a follow up observation and interview on 1/28/2025 at 10:15 a.m., with CNA 3, CNA 3 returned to Resident 129's room and stated the resident was a fall risk and she should not have left the resident's bed in

the high position because the resident was considered at risk for falls. CNA 3 was observed lowering Resident 129's bed to the lowest position.

During an interview on 1/31/2025 at 8:30 a.m., with the Director of Staff Development (DSD), the DSD stated resident beds should not be left in the high position when unattended by staff because a resident could get nervous and fall. The DSD stated there was a higher risk for injuries, like fractures, when a resident falls from

the bed in the high position.

During a concurrent interview and record review on 1/31/2025, at 9:30 a.m., with the Director of Nursing (DON), the DON reviewed the facility policy regarding fall management. The DON stated Resident 129 has confusion and the resident's bed should be in the lowest position when unattended by staff, but it wasn't when CNA 3 left the resident's bed up and left the resident's room. The DON stated the bed in the low position would minimize the risk for injury from falls. The DON stated the facility's policy and procedures were not followed when Resident 129's bed was left up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment last reviewed on 1/22/2025, the P&P indicated the nursing staff, in conjunction with the attending physician, consultant Level of Harm - Minimal harm or pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and potential for actual harm establish a resident centered fall prevention plan based on relevant assessment information. The staff will seek to identify environmental factors that may contribute to falling. Residents Affected - Some

During a review of the facility's P&P titled, Fall Management, last reviewed on 1/22/2025, the P&P indicated

the purpose of the policy was to reduce the risk for falls and minimize the actual occurrence of falls. Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk for falls will receive appropriate interventions to reduce the risk and minimize injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) out of one sampled resident (Resident 137) investigated under the urinary catheter or UTI care area when the facility failed to ensure Residents 137's urinary catheter tubing did not have a loop while hanging on the side the bed.

This deficient practice had the potential to result in the resident's urine to not flow freely which may lead to

the development of an UTI.

Findings:

a. During a review of Resident 137's Admission Record, the admission record indicated the facility originally admitted Resident 137 on 5/21/2024 and readmitted the resident on 1/9/2025, with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and generalized muscle weakness.

During a review of Resident 137's Minimum Data Set (MDS - a resident assessment tool) dated 1/11/2025,

the MDS indicated Resident 137 had impaired cognition (mental action or process of acquiring knowledge and understanding) and required 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 137 had

an indwelling catheter.

During a review of Resident 137's History and Physical (H&P) dated 1/12/2025, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

During a review of Resident 137's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 1/13/2025:

- Change indwelling catheter when occluded or leaking as needed.

- Perform indwelling catheter care every day shift and as needed.

- Indwelling catheter 16 French (FR - a unit of measurement) with ten (10) milliliters (ml - a unit of measurement) balloon to bedside straight drainage for urinary retention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During a concurrent observation and interview on 1/28/2025 at 10:38 a.m. while inside Resident 137's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 verified Resident 137's urinary catheter tubing had a loop, Level of Harm - Minimal harm or and the loop had urine inside. LVN 2 stated the urinary catheter tubing should not have a loop as the urine potential for actual harm will not flow freely or back up into the bladder and cause a UTI. LVN 2 stated Resident 137's should have no loop as it placed the resident at risk for acquiring UTI when the urine in the tubing cannot flow freely and Residents Affected - Few possibly back up into the bladder.

During an interview on 1/30/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated urinary catheter tubing should be positioned properly on the side of the bed to prevent loops or kink as the urine will not flow freely and back up into the bladder and nurses should check every time they go to the resident's room. The DON stated Resident 137's urinary catheter tubing should have been placed properly on the side of the bed to prevent kinks or loops as the urine will not flow freely and back up into the bladder which may lead to an UTI.

During a review of the facility's policy and procedure (P&P) titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, last reviewed on 1/25/2025, the P&P indicated to maintain unobstructed urine flow by keeping the catheter and tubing free of kinks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38552 potential for actual harm Based on observation, interview, and record review, the facility failed to monitor Resident 69's change in Residents Affected - Few condition for significant weight loss for one of two sampled residents (Resident 69) investigated under the nutrition care area.

This deficient practice had the potential to place the resident at risk for further weight loss.

Findings:

During a review of Resident 69's Admission Record, the Admission Record indicated the facility admitted the resident on 11/18/2019 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 69's Weights and Vitals Summary, the Weights and Vitals Summary indicated:

- 1/2/2025, 152.8 pounds (lbs. -a unit of measurement)

- 12/2/2024, 163.7 lbs.

- 11/4/2024, 165.7 lbs.

- 10/6/2024, 165.5 lbs.

- 7/3/2024, 170.3 lbs.

During a review of Resident 69's Nutritional Assessment, dated 1/2/2025, the Nutritional Assessment indicated the resident had significant weight change with recommendations to monitor weight trend, meal intake, and labs as available. The Nutritional Assessment indicated the goals of minimizing further weight loss and maintaining meal intake greater than 75 percent (%) through next review date.

During a review of Resident 69's Change in Condition (COC- a major decline in a resident's status) Evaluation, dated 1/5/2025, the COC Evaluation indicated the resident had a weight loss of 11 lbs. in 30 days and a weight loss of 17 lbs. in 180 days.

During a review of Resident 69's weight loss care plan, dated 1/6/2025, the care plan indicated the goal of having no complications from weight variance and with interventions including monitoring for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and reporting to food and nutrition/physician as indicated.

During a concurrent observation and interview on 1/29/2025 at 1:23 p.m. with Registered Nurse 2 (RN 2), RN 2 stated Resident 69 ate 50% of his meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 1/29/2025 at 1:36 p.m., with RN 2, RN 2 stated Resident 69 had a COC for significant weight loss on 1/5/2025 and that there should have been a monitoring as to why the resident was losing Level of Harm - Minimal harm or weight. RN 2 stated it is important because resident could lead to health deterioration and malnutrition (a potential for actual harm condition that occurs when your diet lacks the nutrients your body needs to function).

Residents Affected - Few During a concurrent interview and record review on 1/29/2025 at 3:19 p.m., with Licensed Vocational Nurse 4 (LVN 4), Resident 69's Progress Notes 1/1/2025 to 2/1/2025 was reviewed. LVN 4 stated she completed

the COC on 1/5/2025, but she did not finish it. LVN 4 stated she remembers calling the doctor and family, but

she does not recall what time. LVN 4 stated there should have been documentation of monitoring after the COC was identified. LVN 4 stated the resident would be at risk for further weight loss if (Resident 69) he was not monitored.

During an interview on 1/31/2025 at 4:52 p.m., with the Director of Nursing (DON), the DON stated there should have been a 72- hour monitoring for any changes in condition. The DON stated when the monitoring is not done there is a potential for not implementing the interventions that are needed to prevent Resident 69 from further weight loss.

During a review of the facility's policy and procedure (P&P) titled, Weight Management, last reviewed and approved on 1/22/2025, the P&P indicated this policy to determine possible causes of significant weight change . the following interventions will be carried out:

a. Notification of attending physician and family member/responsible party by nursing staff.

b. Notification of dietetics professional by nursing staff. The dietetics professional will assess the resident, document the assessment, and make recommendations in the resident's medical record.

During a review of the facility's P&P titled, Change in Condition, Notification of, last reviewed and approved

on 1/22/2025, the P&P indicated the facility must immediately inform the resident, consult with the resident's physician and/or nurse practitioner, and notify, consistent with his/her authority, Resident Representative where there is: a significant change in the resident's physical, [NAME], or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of102 056113 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 44244 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the safe and appropriate use of side rails (SR or bed rail - adjustable, rigid, plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of five sampled residents (Resident 145) reviewed under the Accidents care area by failing to:

1. Attempt to use appropriate alternatives prior to installing bilateral (both sides) upper (at the head and shoulder area) SRs.

2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral upper SRs use.

3. Review the risks and benefits of bilateral upper SRs with the resident or resident representative and obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered).

4. Develop and implement a Care Plan (CP - a written course of action that helps a resident achieve outcomes that improve their quality of life) for the use of SRs.

These deficient practices had the potential to result in physical harm from entrapment and death of residents.

Cross-reference