Alexandria Care Center
ALEXANDRIA CARE CENTER in LOS ANGELES, CA — inspection on January 31, 2025.
Found 32 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 1/30/2025 at 2:30 p.m. with the DON, the DON stated the staff should place the call light within the residents' reach prior to leaving the room to ensure the residents can call for assistance and for the staff to meet their needs.
The DON stated Resident 94's call light should have been within reach to ensure the resident would be able to call for assistance to prevent delay in the provision of care the resident needs, which may lead to Resident 94 getting out of bed unassisted and possibly fall.
During a review of the facility's P&P titled, Answering the Call Light, last reviewed on 1/25/2025, the P&P indicated to ensure that the call light is accessible to the resident when in bed for timely response to the resident's requests and needs.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
be covered and assume financial responsibility.
minimal harm 2.If the resident's Medicare Part A benefits are terminating for coverage reasons, the director of admissions or benefits coordinator issues the Notice of Medicare Non-Coverage (CMS form 10123) to
c) The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination. d) The Notice of Medicare Non-Coverage is not indicated when the resident's Medicare covered days are exhausted; nor is it used to notify the resident of potential liability for payment.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of the facility's P&P titled, Homelike Environment, last reviewed 1/25/2025, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment.
The policy indicated the staff, and management maximizes the characteristics of the facility that reflect a personalized, homelike setting by providing a clean, sanitary, and orderly environment.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
determine the need for restraints.
The assessment shall be used to determine the possible underlying
Restraints shall only be used upon the written order of the physician and after obtaining consent from the resident and/or representative.
The order shall include the following: a.
The specific reason for the restraint. b.
How the restraint will be used to benefit the resident's medical symptom. c.
The type of restraint, and period of time for the use of the restraint. - Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use - Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom (s) but the underlying problems that may be causing the symptom(s) - Care plans shall also include the measures taken to systematically reduce or eliminate the needs for restraint use
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
prescribing, monitoring, and review requirements specific to psychotropic medications:
minimal harm a.
b.
Anti-depressants
- Consideration of the use of any psychotropic medication is based on comprehensive review of the
- When determining to initiate .medication therapy, the IDT conducts an evaluation of the resident.
resident.
The evaluation will attempt to clarify whether: a.
Signs and symptoms are clinically significant enough to warrant medication therapy b.
A particular medication is clinically indicated to manage the symptoms or condition.
During an interview on 1/31/2025 at 4:39 p.m. with the Director of Nursing (DON), the DON stated Resident 48's PASRR first diagnoses and medication resulted in level 1 positive.
The DON stated if a resident had any mental changes, they would need to submit a new PASRR screening.
The DON stated they had to ensure that the completed PASRR was correct and appropriate.
The DON stated when PASRRs are not completed accurately it could potentially place the residents for missed opportunities and services.
During a review of the facility's policy and procedure (P&P) titled, PASRR Completion Policy, last reviewed and approved on 1/22/2025, the P&P indicated the facility will make sure that all admissions have the appropriate PASRR completed.
The P&P indicated the designated staff will ensure that the PASRR is done and completed.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
or representative, must develop and implement a comprehensive person-centered care for each
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 arc reviewed and revised as information about the resident and the resident 's condition change.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
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 resident's who express a desire to smoke upon admission, quarterly, annually, significant change of 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 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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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).
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs
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 arc reviewed and revised as information about the resident and the resident 's condition change.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of the facility's operator's manual, titled Med Aire Plus 8 Alternating Pressure and
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
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 pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and 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.
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a concurrent observation and interview on 1/29/2025 at 1:23 p.m. with Registered Nurse 2 (RN
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 weight. RN 2 stated it is important because resident could lead to health deterioration and malnutrition (a condition that occurs when your diet lacks the nutrients your body needs to function).
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a concurrent observation and interview with Resident 145, on 1/28/2025, at 8:45 a.m., inside
145 stated the SRs are always up.
During a concurrent observation, interview, and record review with Minimum Data Set Nurse (MDSN) 1 and Registered Nurse (RN) 1, on 1/30/2025, at 8:45 a.m., Resident 145's physician orders, Bed Rail Evaluation, dated 11/23/2024, CPs, and informed consents were reviewed. MDSN 1 entered Resident 145's room and stated the resident had bilateral upper SRs in use. RN 1 stated the process for the use of SRs is to first attempt to use alternatives prior to SRs use, then a safety assessment should be completed, and informed consent should be obtained with the physician's order. RN 1 stated Resident 145's most recent bed rail evaluation indicated the use of SRs was not recommended. RN 1 stated Resident 145 had a physician's order for the use of SRs and the SR evaluation was not completed correctly. RN 1 stated when the SR evaluation was not completed correctly it resulted in the following: no alternatives to SRs were attempted prior to the use of SRs, the resident was not assessed for safety and the risk for entrapment, and informed consent was not obtained. RN 1 stated it was important to attempt alternatives, assess the resident for safety, and obtain consent because SRs can lead to injury of the resident. RN 1 stated CPs 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 SR CP was to know if resident goals, like remaining free of injury from the use of SRs, were met or not met. RN 1 stated Resident 145 did not have a CP for the use of SRs, but the resident should have had a CP.
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, Siderails, last reviewed 1/22/2025, was reviewed.
The DON stated there is a process for the use of SRs that includes an assessment to determine the safety of SR use and to explain the risk of the SRs to the resident while obtaining informed consent.
The DON stated this process was not followed when the facility used SRs on Resident 145 without a safety assessment, without attempting alternatives, and without obtaining informed consent.
The DON stated when the facility P&P was not followed it could have potentially resulted in entrapment of the resident.
During a review of the facility's 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 Interdisciplinary Team (IDT) will determine whether a resident should be provided with side rails on his/her bed, based on an individual assessment which includes the risk for entrapment.
Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.
Following admission and/or as a resident's condition necessitates, a licensed nurse and or the IDT attempt at less restrictive approaches and evaluating their effectiveness will be part of the IDT recommendations and review.
The licensed nurse will complete the Bedrail Evaluation and develop a Care Plan reflecting the evaluation.
The IDT will discuss the risks involved with SRs with the resident and/or the resident's surrogate decision maker and caregivers and describe alternatives that may be safer and feasible.
Prior to placing the SRs on the bed, informed consent will be obtained when SR meets the definition of a restraint even when it is also an enabler.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of the facility ' s policy and procedures (P&P) titled, Controlled Substances, last reviewed 1/22/2025, the P&P indicated The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of CM.
- Waste and/or disposal of CMs are done in the presence of the nurse and a witness who also signs
- Accountability records for discontinued CS are kept with the unused supply until it is destroyed or
the disposition sheet.
disposed of as required by applicable law or regulation.
During a review of the P&P titled, Discarding and Destroying Medications, last reviewed 1/22/2025, the P&P indicated Medications . are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
Schedule II, III, and IV (non-hazardous) CS will be disposed of in accordance with the state regulations and federal guidelines regarding disposition of non-hazardous CM.
The medication disposition record will contain .: Signature of witnesses.
During a review of the P&P titled, Controlled Medication Disposal, last reviewed 1/22/2025, the P&P indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
The DON and the Consultant Pharmacist are responsible for the facility ' s compliance with federal and state laws and regulations in the handling of CMs.
When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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 order writing.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
- Psychotropic medications to treat behaviors will be used appropriately to address specific underlying
medical or psychiatric causes of behavioral symptoms.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
dosage, right time and right method (route) of administration before giving the medication.
indicated:
b.
Medication Error means the administration of medication: At the wrong time Which is not currently prescribed.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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).
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
- Drugs and biologicals used in the facility are stored in locked compartments under proper
- Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy
temperature, light and humidity controls.
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.
- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean,
- Multi-dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded
safe, and sanitary manner.
within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During an interview on 1/28/2025 at 11:12 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
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.
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
F 0804 -
-
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.
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 holding, and less than 41°F for cold food holding.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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 product needs thinning.
Add commercial thickener if product needs thickening.
During a review of the facility's recipe titled, Corn, Creamed Style (can) ½ 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).
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During an observation and interview on 1/29/2025 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 1/22/2025, 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 1/22/2025, the P&P indicated, (5) Refrigerator/freezers for storage of food brought in by visitors will properly be maintained, and: - Equipped with thermometers - Have temperature monitored daily for refrigeration less than or equal to 41°F and freezer less than or equal to 0°F.
During a review of Food Code 2022, dated 1/18/2023, the Food Code indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a 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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 120's physician order dated 12/3/2024, the physician order indicated
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]/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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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.
056113 01/31/2025
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 10's Admission Record (a document containing demographic and diagnostic information), dated 1/30/2025, the Admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including morbid obesity.
During a review of Resident 10's MAR, dated January 2025, printed 1/29/2025, at1:06 p.m., the MAR indicated that Resident 10 was prescribed and had an active order for:
1.) rivaroxaban (a blood thinner medication used for Deep Vein Thrombosis [DVT - a condition that forms blood clots in the body]) 10 milligram (mg - a unit of measure of mass) tablet to be given orally at bedtime at 9:00 p.m. starting 5/28/2024, and
2.) rivaroxaban 10 mg tablet to be given orally at bedtime at 9 p.m. starting 1/19/2025.
The MAR indicated that both rivaroxaban 10 mg doses were signed off as administered from the following licensed nurses on the following times/dates:
Licensed Vocational Nurse (LVN) 9 - at 9:00 p.m., on 1/20/2025 and 1/21/2025
Registered Nurse (RN) 3 - at 9:00 p.m., on 1/22/2025 and 1/23/2025
LVN 3 -at 9:00 p.m., on 1/24/2025
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 51's Admission Record (a document containing demographic and diagnostic information,) the admission record indicated the facility originally admitted Resident 51 on 3/5/2019 and readmitted the resident on 6/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 11/9/2024, the MDS indicated Resident 51 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial /moderate assistance with personal hygiene and rolling left and right; substantial/maximal assistance with upper body dressing, lower body dressing, , and sit to lying/lying to sitting; total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
The MDS indicated Resident 51 received insulin.
During a review of Resident 51's History and Physical (H&P) dated 6/19/2024, the H&P indicated Resident 51 did not have the capacity to understand and make decisions.
During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:
- 6/11/2024: Insulin glargine-yfgn (Lantus -a long-acting insulin) subcutaneous (SQ - under the skin]) solution pen-injector 100 unit per ml (unit/ml - a unit of measurement) inject 15 units SQ at bedtime for DM.
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 145's Admission Record, the Admission Record indicated the facility admitted the resident on 10/23/2024 and readmitted the resident on 11/23/2024 with diagnoses that included spinal
potential for actual harm radiculopathy (a condition that occurs when a nerve in the spine is damaged or irritated, often called a pinched nerve), cervical region (area at the neck), lack of coordination, and muscle weakness.
During a review of Resident 145's Order Summary Report, the report indicated an order for bed rails as enabler for turning and repositioning in bed, dated 11/23/2024.
During a review of Resident 145's Minimum Data Set (MDS - resident assessment tool) dated 11/29/2024, the MDS indicated the resident was able to understand others and was able to make herself understood.
The MDS further indicated the resident had an impairment on one side of the upper extremities, was dependent on staff for toileting and bathing, and required partial/moderate assistance for personal and oral hygiene.
The MDS indicated the resident required substantial/maximal assistance from staff for transferring from the bed to chair, rolling left to right in the bed, and moving from sitting to lying.
During a concurrent observation and interview on 1/28/2025 at 8:45 a.m., Resident 145 lay in bed with bilateral (both sides) upper siderails in the raised position. Resident 145 stated the siderails are always up.
During a concurrent observation, interview, and record review on 1/30/2025 at 8:45 a.m. with Minimum Data Set Nurse 1 (MDSN 1) and Registered Nurse 1 (RN 1), MDSN 1 and RN 1 reviewed Resident 145's physician orders and care plans. MDSN 1 entered Resident 145's room and stated the resident had bilateral upper siderails in use. RN 1 stated Care Plans are used to provide a resident's care with resident specific interventions and goals. RN 1 stated resident's using SRs should have a CP for the use of SRs. RN 1 stated the importance of the siderail care plan was to know if resident goals, like remaining free of injury from the use of siderails, were met or not met. RN 1 stated Resident 145 did not have a care plan for the use of siderails but should have.
During an interview on 1/31/2025 at 9:30 a.m. with the Director of Nursing (DON), the DON stated resident centered care plans specify resident's specific needs and problems.
The DON stated care plans are followed for each resident to deliver the right intervention for the resident.
The DON stated the facility policy was not followed when Resident 145 did not have a care plan for the use of siderails.
During a review of the facility Policy and Procedure (P&P) titled, Siderails, last reviewed 1/22/2025, the P&P indicated the purpose of the policy was to ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms.
The LN will complete the Bedrail Evaluation and develop a Care Plan reflecting the evaluation.
During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed 1/22/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident.
The facility's IDT, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident.
Each resident ' s comprehensive care plan is designed to:
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
During a review of Resident 51's Admission Record, the Admission Record indicated the facility originally admitted Resident 51 on 3/5/2019 and readmitted the resident on 6/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness.
During a review of Resident 51's Minimum Data Set (MDS - a resident assessment tool) dated 11/9/2024, the MDS indicated Resident 51 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; partial /moderate assistance with personal hygiene and rolling left and right; substantial/maximal assistance with upper body dressing, lower body dressing, , and sit to lying/lying to sitting; total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
The MDS indicated Resident 51 received insulin.
During a review of Resident 51's History and Physical (H&P) dated 6/19/2024, the H&P indicated Resident 51 did not have the capacity to understand and make decisions.
During a review of Resident 51's Order Summary Report, the Order Summary Report indicated the following physician's orders dated:
- 6/11/2024: Insulin glargine-yfgn (Lantus -a long-acting insulin) subcutaneous solution pen-injector 100 unit/ml inject 15 units subcutaneously at bedtime for DM.
- 6/12/2024 to 10/31/2024; 10/31/2024 to 12/6/2024: Insulin lispro MUV 100 unit/ml vial.
Inject subcutaneously before meals and at bedtime for DM.
Inject as per sliding scale: if 140 - 199 = 1; < 70 and conscious glucogel (a gel form of glucose which provides a direct source of sugar 1pack or 4 oz juice, if unconscious, give glucagon IM one time and call MD; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 400 = 5. If blood sugar is greater than 400 mg per deciliter (dl - a unit of measurement) administer 5 units and Call MD.
056113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056113 B.
Wing 01/31/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alexandria Care Center 1515 N Alexandria Ave.
Los Angeles, CA 90027
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.