Inspection Reports for
Alexandria Care Center
1515 Alexandria Ave, Los Angeles, CA 90027, United States, CA, 90027
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
24.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
520% worse than California average
California average: 4 deficiencies/year
Deficiencies per year
36
27
18
9
0
Inspection Report
Routine
Deficiencies: 4
Date: Jan 28, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medical record accuracy, infection control, and care planning at Alexandria Care Center.
Findings
The facility was found deficient in monitoring the use of bed alarm devices as physical restraints, developing and implementing complete and updated care plans, maintaining accurate and complete medical records, and providing clean and sanitary utensils to residents. These deficiencies posed risks of unnecessary restraint, resident falls, incomplete care, inaccurate documentation, and potential infections.
Deficiencies (4)
F 0604: The facility failed to ensure one resident was free from physical restraint by not monitoring and documenting the use of a bed alarm device, risking unnecessary restraint and resident harm.
F 0656: The facility failed to develop and implement a complete, person-centered care plan for one resident, resulting in confusion of care and increased fall risk due to lack of updated interventions after room change and discontinuation of wander guard.
F 0842: The facility failed to maintain accurate and complete medical records for one resident by not documenting timely physician notification, nursing interventions, and incident details related to falls.
F 0880: The facility failed to implement infection control measures by providing a resident with a dirty spoon, risking foodborne illness and infection.
Report Facts
Residents sampled: 3
Dates of incidents and reviews: Jan 10, 2026
Dates of incidents and reviews: Jan 14, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Observed bed alarm use and fall incident response for Resident 2 |
| Director of Nursing | DON | Provided statements on deficiencies related to bed alarm monitoring, care plan updates, medical record documentation, and infection control |
| Registered Nurse 2 | RN | Assessed Resident 2 after fall and called 911; failed to document interventions |
| Dietary Supervisor | DS | Received complaint about dirty spoon and discussed utensil sanitation |
| Social Service Director | SSD | Received complaint about dirty spoon and confirmed infection risk |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 30, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to care planning, medication administration, medical record accuracy, infection prevention and control, and antibiotic stewardship at Alexandria Care Center.
Findings
The facility was found deficient in developing timely and complete care plans for a resident with legionnaires disease and antibiotic use, clarifying and following physician medication orders, maintaining accurate medical records, implementing infection control measures including use of personal protective equipment, and monitoring antibiotic use and side effects.
Deficiencies (5)
F 0656: The facility failed to develop and implement a complete care plan for legionnaires disease and azithromycin use for a resident, delaying necessary care interventions.
F 0755: The facility failed to clarify physician orders for famotidine and to follow orders for guaifenesin and dextromethorphan, resulting in medication administration errors with potential side effects.
F 0842: The facility failed to maintain accurate medical records by incorrectly documenting oxygen device use for a resident, risking confusion in care.
F 0880: The facility failed to implement infection control measures by staff not wearing required masks, gowns, and gloves when providing care to residents on enhanced barrier precautions, risking infection spread.
F 0881: The facility failed to implement an antibiotic stewardship program by not monitoring a resident for use and adverse effects of azithromycin, risking antibiotic resistance and adverse reactions.
Report Facts
Medication doses: 4
Medication doses: 8
Medication doses: 2
Oxygen liters: 15
Antibiotic dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | RN | Reviewed care plans and medication administration for Resident 1 |
| Licensed Vocational Nurse 1 | LVN | Reviewed physician orders and medication administration for Resident 1 |
| Director of Nursing | DON | Provided statements on care plan development, medication errors, and infection control |
| Infection Preventionist | IP | Provided statements on infection control and antibiotic monitoring |
| Registered Nurse 3 | RN | Documented oxygen administration and provided interview on medical record accuracy |
| Registered Nurse 4 | RN | Observed not wearing PPE during IV care for Resident 2 |
| Licensed Vocational Nurse 2 | LVN | Observed not wearing PPE during care for Resident 2 |
| Licensed Vocational Nurse 3 | LVN | Observed not wearing gown during gastrostomy tube care for Resident 6 |
| Director of Staff Development | DSD | Provided statements on medication order clarification and medication errors |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 28, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to urinary catheter care and emergency exit safety in the nursing home.
Findings
The facility failed to provide proper care and monitoring for a resident with an indwelling suprapubic catheter, including lack of wound dressing, failure to anchor the catheter, and inadequate monitoring for urinary tract infection. Additionally, one emergency exit door was found blocked by chairs, posing a safety hazard.
Deficiencies (2)
F 0690: The facility failed to ensure Resident 1's suprapubic catheter stoma had a wound dressing, the catheter tubing was anchored, and monitoring for urinary tract infection was documented as required.
F 0921: The facility failed to ensure one of four emergency exit doors was free from obstructions, blocking egress and posing a danger to residents and staff.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 2 | Provided observations and statements regarding Resident 1's catheter care and emergency exit door obstruction. | |
| Director of Nursing (DON) | Provided statements confirming failures in catheter care monitoring and emergency exit door safety. |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 1, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including call light accessibility, care plan implementation, pressure ulcer prevention, pharmaceutical services, and medical record accuracy.
Findings
The facility failed to ensure call lights were within reach for three sampled residents, did not follow care plan settings for a low air loss mattress leading to potential skin injury, failed to provide pharmaceutical services according to physician orders for one resident, and had inaccurate medical record documentation for another resident.
Deficiencies (5)
F 0558: The facility failed to ensure call light devices were within reach for three sampled residents, potentially delaying care and assistance.
F 0656: The facility failed to implement a person-centered care plan by not following the low air loss mattress setting for one resident, risking pressure ulcers.
F 0686: The facility failed to ensure the low air loss mattress machine was functioning properly, with incorrect settings and unresolved low pressure alarms, risking pressure ulcers for one resident.
F 0755: The facility failed to follow physician orders by administering blood pressure medications despite low blood pressure readings, risking hypotension for one resident.
F 0842: The facility failed to maintain accurate and complete medical records for one resident, resulting in inaccurate documentation of anticoagulant monitoring and potential confusion in care.
Report Facts
Resident weight: 111.8
LALM setting: 200
Medication dosage: 6.25
Medication dosage: 50
Blood pressure: 104
Blood pressure: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Administered blood pressure medications to Resident 2 despite low blood pressure and physician orders to hold. |
| Certified Nursing Assistant 1 | CNA | Reported low air loss mattress low pressure light on Resident 1's mattress and call light not within reach. |
| Treatment Nurse 1 | TN | Fixed low air loss mattress on 3/27/2025 and explained mattress settings and risks. |
| Director of Nursing | DON | Provided statements on facility policies, care plan adherence, and medication administration. |
| Director of Staff Development | DSD | Commented on medication administration errors and mattress settings. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged resident-to-resident physical abuse incident that occurred on 2025-02-17 involving two residents at the facility.
Complaint Details
The complaint investigation substantiated that Resident 2 was physically abused by Resident 3 on 2025-02-17 at approximately 6:25 p.m. The incident was witnessed by CNA 1 and LVN 1, and Resident 2 reported pain and fear due to Resident 3's behavior. Resident 3 has a history of confusion and wandering into other residents' rooms.
Findings
The facility failed to protect Resident 2 from physical abuse by Resident 3 when Resident 3 hit Resident 2 on the right side of her head. Resident 2 experienced mild pain and was treated with acetaminophen. The incident was witnessed by staff and confirmed through interviews and record reviews.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Resident 3 hit Resident 2 on the right temporal side causing pain rated 3 out of 10, requiring acetaminophen treatment.
Report Facts
Pain scale: 3
Medication dosage: 325
Medication administration time: 1853
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA 1) | Witnessed the abuse incident between Resident 3 and Resident 2. | |
| Licensed Vocational Nurse (LVN 1) | Witnessed the incident and provided care to Resident 2. | |
| Administrator | Interviewed regarding the incident and facility response. |
Inspection Report
Inspection Report
Deficiencies: 16
Date: Jan 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication management, environment safety, infection control, and nutrition.
Findings
The facility was found deficient in multiple areas including call light accessibility, beneficiary notification documentation, cleanliness of resident environment, use of physical restraints, accuracy of resident assessments, PASRR screening, care planning, medication administration and monitoring, food service quality and safety, infection prevention, and medication storage and disposal.
Deficiencies (16)
F 0558: Facility failed to ensure call lights were within reach for residents 33 and 94, risking delayed care and potential injury.
F 0582: Facility failed to provide written Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Non-Coverage to residents 13 and 118, risking residents' rights to informed financial decisions.
F 0584: Facility failed to maintain cleanliness of Resident 10's electric stand fan, risking resident quality of life and potential infection.
F 0604: Facility used pillows tucked under fitted sheet as restraints for Resident 95 without physician order, assessment, consent, or care plan, restricting freedom of movement.
F 0641: Facility failed to accurately complete Resident 21's admission diagnosis and MDS assessment, omitting schizophrenia and bipolar disorder, risking inadequate care planning.
F 0645: Facility failed to submit a new Level 1 PASRR for Resident 48 after diagnosis and medication changes, risking inappropriate placement and missed services.
F 0656: Facility failed to develop and implement care plans for Residents 145 (side rails), 141 (Pradaxa monitoring), 147 (therapy refusals), and 86 (low air loss mattress), risking harm from inadequate care.
F 0658: Facility failed to dispose of controlled substances and medications awaiting disposal properly, and failed to label insulin and eye drops per manufacturer guidelines, risking medication diversion and resident harm.
F 0757: Facility failed to ensure residents' drug regimens were free from unnecessary medications including duplicate rivaroxaban orders for Resident 10 and lack of monitoring for Pradaxa side effects for Resident 141.
F 0758: Facility failed to ensure psychotropic medications for Residents 21 and 358 were prescribed and monitored for specific measurable behavioral manifestations, risking unnecessary medication use and adverse effects.
F 0759: Facility medication error rate was 10.35% with errors including wrong aspirin form for Resident 257 and wrong timing of metformin and aspirin for Resident 109, risking adverse effects.
F 0803: Facility failed to follow menu and portion size guidelines resulting in residents on puree and soft mechanical diets receiving less than prescribed portions and inappropriate food substitutions.
F 0804: Facility failed to serve food at safe and appetizing temperatures; sliced pears and coleslaw were served at unsafe temperatures risking foodborne illness.
F 0812: Facility failed to maintain kitchen and food storage areas in a clean and sanitary condition including dirty refrigerator and freezer floors, dust on vents, uncovered light bulbs, dented cans, cracked trays, wet stacked pots and pans, staff wearing jewelry, and expired food in refrigerators.
F 0842: Facility failed to maintain accurate medication administration documentation for Residents 116 and 120, risking inaccurate medical records and potential medication errors.
F 0880: Facility failed to maintain infection prevention and control practices by not labeling Resident 357's urinal and not placing Resident 21's nebulizer tubing in plastic storage bag after use, risking infection transmission.
Report Facts
Medication errors: 3
Residents on puree diet: 27
Residents on soft mechanical diet: 15
Residents on puree diet: 7
Residents on regular diet: 10
Resident trays: 21
Expired food items: 3
Medication errors: 3
Medication errors: 2
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Verified insulin administration sites not rotated for Resident 51 and 137 |
| LVN 2 | Licensed Vocational Nurse | Verified insulin administration sites not rotated for Resident 51 and 137 |
| DON | Director of Nursing | Reviewed multiple medication and care deficiencies and policies |
| DS | Dietary Supervisor | Interviewed about food portion and kitchen sanitation issues |
| DM | District Manager | Interviewed about food safety and kitchen sanitation issues |
| LVN 4 | Licensed Vocational Nurse | Observed medication storage and labeling issues |
| RN 2 | Registered Nurse | Verified Resident 21's HHN setup contamination risk |
| MDSN 1 | Minimum Data Set Nurse | Discussed psychotropic medication monitoring |
| PT 1 | Physical Therapist | Reported Resident 147 therapy refusals and care plan issues |
| SSA 1 | Social Services Assistant | Discussed Resident 147 therapy refusals documentation |
| RP 1 | Responsible Party | Reported Resident 147 therapy refusals |
| CNA 4 | Certified Nursing Assistant | Reported LALM settings and alarms |
| LVN 5 | Licensed Vocational Nurse | Unaware of LALM malfunction |
| BOA | Business Office Assistant | Discussed beneficiary notification forms |
| ADM | Administrator | Discussed beneficiary notification forms and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 31, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the facility's care and safety practices.
Findings
The facility was found deficient in developing comprehensive care plans, ensuring resident supervision to prevent elopement, managing enteral feeding properly, and maintaining accurate medical records. Deficiencies had minimal harm or potential for actual harm to residents.
Deficiencies (4)
F 0656: The facility failed to develop a comprehensive care plan for a resident refusing shower, resulting in delayed provision of necessary care and services.
F 0689: The facility failed to provide adequate supervision to prevent elopement of a resident who left the facility unassisted without a mobility aid, risking injury and accidents.
F 0693: The facility failed to ensure enteral feeding supplies were properly labeled, feeding was administered at the required times, and total feeding amounts were monitored for two residents, risking inaccurate nutrition and infection.
F 0842: The facility failed to accurately document a resident's history of elopement and shower provision for another resident, risking confusion in care and inaccurate medical records.
Report Facts
Residents affected: 3
Enteral feeding volume: 2213
Enteral feeding volume: 2160
Date of survey completion: Dec 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 4 | LVN | Reported resident refusal of shower and care plan uncertainty |
| Certified Nursing Assistant 1 | CNA | Reported resident refusal of shower |
| Director of Nursing | DON | Provided interviews and reviewed care plans and policies related to deficiencies |
| Registered Nurse 2 | RN | Observed enteral feeding practices and reported deficiencies |
| Licensed Vocational Nurse 3 | LVN | Assigned nurse during resident elopement incident |
| Licensed Vocational Nurse 1 | LVN | Participated in search for eloped resident |
| Licensed Vocational Nurse 2 | LVN | Participated in search for eloped resident |
| Administrator | ADM | Provided interviews regarding policies and incident details |
| Infection Preventionist | IP | Responded to elopement notification and activated code pink |
| Receptionist | RCP | Allowed resident to leave facility mistakenly assuming visitor status |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements regarding resident safety, environmental conditions, and care standards at Alexandria Care Center.
Findings
The facility failed to maintain safe and comfortable temperature levels between 71°F and 81°F for residents, resulting in discomfort for sampled residents. Additionally, the facility failed to prevent possession of hazardous items by residents, specifically a wire cutter found in Resident 2's possession, posing a risk of injury.
Deficiencies (2)
F 0584: The facility failed to maintain the temperature between 71°F and 81°F as required by policy, with temperatures measured as low as 68°F in resident rooms. The temperature log showed multiple days without monitoring, and residents reported feeling cold in their rooms.
F 0689: The facility failed to prevent Resident 2 from possessing a wire cutter, a sharp tool not listed on the Inventory of Personal Effects, posing a risk of injury to the resident and others.
Report Facts
Temperature readings: 68
Temperature readings: 68.3
Temperature readings: 69.6
Dates missing temperature checks: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Named in relation to wire cutter possession incident with Resident 2 |
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding Resident 3's room temperature and condition |
| Licensed Vocational Nurse 2 | LVN | Reviewed Resident 2's Inventory of Personal Effects |
| Director of Nursing | DON | Provided statements regarding facility temperature standards and wire cutter incident |
| Maintenance Director | MtD | Measured facility temperatures and provided temperature log information |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to timely notify the resident's medical doctor and responsible party about a purple discoloration to the resident's left eye.
Complaint Details
The complaint was substantiated. The facility did not notify the resident's family member or medical doctor in a timely manner about the resident's purple discoloration under the left eye, despite staff being aware of the condition on 6/9/2024 and the family member reporting it on 6/16/2024.
Findings
The facility failed to notify the resident's medical doctor and family member timely about the purple discoloration under the resident's left eye, potentially delaying necessary care. Interviews with staff and family confirmed the delay in notification and failure to initiate a timely change of condition.
Deficiencies (1)
F 0580: The facility failed to notify the resident's medical doctor and responsible party timely when a resident was noted with purple discoloration to the left eye. This delay could have resulted in missed opportunities for appropriate care and family involvement.
Report Facts
Date of resident's change of condition noted: Jun 16, 2024
Date of staff observation: Jun 9, 2024
Date of family member visit and report: Jun 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA 1) | Reported purple discoloration under resident's left eye on 6/9/2024 | |
| Licensed Vocational Nurse (LVN 1) | Assessed resident on 6/9/2024 and 6/10/2024 but did not notify doctor or family timely | |
| Director of Nurses (DON) | Stated LVN 1 should have initiated change of condition and notified doctor and family | |
| Administrator (ADMIN) | Initiated investigation after family member report on 6/19/2024 |
Inspection Report
Routine
Deficiencies: 23
Date: Jan 11, 2024
Visit Reason
Routine state inspection survey of Alexandria Care Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, informed consent for medications, call light accessibility, survey result posting, timely submission of Minimum Data Set (MDS) assessments, accuracy of resident assessments, care planning, medication administration, nutritional services, infection control, hospice care coordination, and documentation practices.
Deficiencies (23)
F 0550: Facility failed to ensure Certified Nursing Assistant knocked and requested permission before entering resident rooms, affecting dignity for three residents.
F 0552: Facility failed to ensure informed consent for administration of olanzapine included dosage, route, frequency, and indication for one resident.
F 0558: Facility failed to keep call light within reach of one resident, risking delayed care and falls.
F 0577: Facility failed to post most recent survey results in a prominent accessible location for residents and families.
F 0640: Facility failed to timely submit and transmit Minimum Data Set (MDS) assessments for three residents, risking inadequate care planning.
F 0641: Facility failed to accurately code discharge destination for one resident, risking delay in necessary care and services.
F 0656: Facility failed to develop care plans addressing extrapyramidal symptoms, insulin use, and psychotropic medication for four residents.
F 0658: Facility failed to rotate insulin injection sites for two residents, risking lipodystrophy and skin trauma.
F 0661: Facility failed to provide pharmaceutical services ensuring accurate medication administration and reconciliation for four residents, including controlled substances and medication crushing practices.
F 0686: Facility failed to ensure safe food storage and preparation practices including unlabeled food, dirty equipment, and improper storage of resident brought-in food.
F 0692: Facility failed to provide nutritional supplement as ordered for one resident, risking weight loss.
F 0694: Facility failed to provide safe and appropriate administration of IV fluids for one resident by not labeling IV site and documenting insertion.
F 0695: Facility failed to ensure residents received necessary respiratory care including correct oxygen administration for one resident.
F 0697: Facility failed to provide safe and appropriate pain management by failing to assess and document pain every shift for one resident.
F 0744: Facility failed to provide appropriate treatment and services to a resident with dementia by failing to implement person-centered care plan interventions and improperly closing resident's door during verbal outbursts.
F 0755: Facility failed to provide pharmaceutical services to meet residents' needs including controlled substance reconciliation, medication administration, and medication crushing practices for four residents.
F 0761: Facility failed to ensure medication error rate was less than 5% with three medication errors observed in two residents.
F 0803: Facility failed to ensure menus met nutritional needs, were prepared as planned, and followed recipes, resulting in incorrect portion sizes and food preparation for multiple residents.
F 0804: Facility failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures for residents, resulting in meal dissatisfaction and decreased intake.
F 0812: Facility failed to ensure therapeutic diets were prescribed by attending physician and delegated appropriately to dietitian for residents on nutritional supplements.
F 0842: Facility failed to safeguard resident-identifiable information and maintain medical records accurately including failure to document medication administration and death pronouncement.
F 0849: Facility failed to arrange for provision of hospice services and ensure collaboration and documentation of hospice care for four residents.
F 0880: Facility failed to implement infection prevention and control program including failure to label resident equipment, perform hand hygiene, maintain clean enteral feeding pump, and keep oxygen tubing off floor for multiple residents.
Report Facts
Medication errors: 3
Medication doses missed: 10
Weight loss percentage: 18.57
Residents missing nutritional supplements: 17
Residents affected by infection control lapses: 9
Residents on pureed diet receiving incorrect food: 2
Residents on renal diet receiving incorrect protein portion: 5
Residents on regular and dysphagia diet receiving less corn: 118
Unlabeled food items in refrigerator: 4
Unlabeled respiratory tubing: 1
Unlabeled urinal bottles: 1
Oxygen tubing touching floor: 1
Medication error rate: 10.71
Insulin pen days past expiration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Failed to knock before entering rooms and failed hand hygiene |
| LVN 2 | Licensed Vocational Nurse | Mixed medications for Resident 67 and failed to document IV line changes |
| LVN 3 | Licensed Vocational Nurse | Failed to rotate insulin injection sites for Resident 306 and failed to document medication administration |
| LVN 6 | Licensed Vocational Nurse | Failed to label respiratory tubing for Resident 112 |
| HSK 1 | Housekeeping Staff | Failed hand hygiene and cleaned multiple rooms without glove changes |
| LVN 10 | Licensed Vocational Nurse | Failed to reconcile controlled drug record with medication administration |
| LVN 9 | Licensed Vocational Nurse | Failed to administer medications as ordered for Resident 99 |
| LVN 7 | Licensed Vocational Nurse | Failed to discard expired insulin pen for Resident 20 |
| CNA 3 | Certified Nursing Assistant | Closed resident door during verbal outbursts without reporting behavior |
| DON | Director of Nursing | Provided multiple statements on deficiencies and facility policies |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 11, 2023
Visit Reason
The inspection was conducted to assess compliance with resident dignity rights and infection prevention and control measures during a COVID-19 outbreak.
Findings
The facility failed to maintain resident dignity by not covering a urinary collection bag for one resident and failed to enforce proper use of N95 respirators among staff during a COVID-19 outbreak, potentially increasing infection risk.
Deficiencies (2)
F 0550: The facility failed to provide care maintaining resident dignity by not covering Resident 1's urinary collection bag with a privacy cover.
F 0880: The facility failed to maintain infection prevention by not ensuring three staff members wore N95 respirators during a COVID-19 outbreak, risking spread of infection.
Report Facts
COVID-19 positive residents: 10
Sampled staff noncompliant with N95 use: 3
Residents affected by dignity deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Interviewed regarding urinary collection bag privacy | |
| Director of Nursing | Interviewed regarding urinary bag privacy and COVID-19 outbreak precautions | |
| Admission Director | Observed not wearing N95 respirator during COVID-19 outbreak | |
| Licensed Vocational Nurse 1 | Observed not wearing N95 respirator during COVID-19 outbreak | |
| Certified Nursing Assistant 1 | Observed not wearing N95 respirator during COVID-19 outbreak |
Inspection Report
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the safeguarding of resident-identifiable information and maintenance of medical records, specifically focusing on the completeness of the Resident's Clothing and Possessions form upon admission.
Findings
The facility failed to maintain a completely filled out Resident's Clothing and Possessions form for one sampled resident. The staff did not obtain the signature of either the resident or responsible party when receiving belongings upon admission, posing a risk of loss or misplacement of personal items.
Deficiencies (1)
F842 Resident Records - Identifiable Information: The facility failed to maintain a completely filled out Resident's Clothing and Possessions form for one sampled resident. Staff did not obtain the signature of the resident or responsible party upon admission, risking loss of belongings.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 (LVN 1) | Interviewed regarding incomplete inventory and signature on Resident's Clothing and Possessions form. | |
| Social Services Director (SSD) | Interviewed regarding facility policy on inventory of resident personal effects upon admission. |
Inspection Report
Deficiencies: 3
Date: Sep 22, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident record-keeping and medication administration documentation standards at Alexandria Care Center.
Findings
The facility failed to ensure six medications were properly signed off for one sampled resident, resulting in inaccurate documentation of the resident's medical record. The Director of Nursing confirmed that missing documentation in the Medication Administration Record (MAR) was not acceptable and should be corrected promptly.
Deficiencies (3)
F842 Resident Records - Identifiable Information: The facility failed to safeguard resident-identifiable information and maintain complete, accurate, and accessible medical records in accordance with professional standards.
The facility failed to ensure six medications were signed off on the Medication Administration Record for one resident on multiple dates, resulting in inaccurate medication documentation.
Timely entry of documentation must occur as soon as possible after care provision and conform to facility policies and procedures.
Report Facts
Medication administration dates missing signatures: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 3 | Registered Nurse | Interviewed regarding missing medication administration signatures for Resident 1. |
| Director of Nursing | Director of Nursing | Confirmed missing documentation in the Medication Administration Record and emphasized the need for timely signing off. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from physical abuse and resident-to-resident altercations at Alexandria Care Center.
Complaint Details
The complaint investigation substantiated that Residents 1, 2, and 6 experienced physical abuse due to inadequate supervision and failure to prevent altercations. The incidents included Resident 1 pinning Resident 2 down during a dining room altercation and Resident 6 hitting Resident 1 with a plate lid. Staff interviews confirmed insufficient supervision in the dining area and nursing station at the times of incidents.
Findings
The facility failed to protect residents from physical abuse by not implementing adequate safety measures to prevent altercations among residents. Multiple incidents involving Residents 1, 2, and 6 were documented, including physical injuries and aggressive behaviors.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse by not implementing safety measures to prevent resident-to-resident altercations involving Residents 1, 2, and 6. This resulted in physical injuries such as abrasions and cuts to the residents involved.
Report Facts
Date of survey completion: Sep 19, 2023
Size of skin injuries: 0.2
Size of skin injuries: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Reported partial visual supervision during dining room altercation and confirmed need for staff presence in dining area |
| Certified Nursing Assistant 4 | CNA | Witnessed altercation between Resident 1 and Resident 6 and intervened to stop it |
| Registered Nurse 2 | RN | Interviewed Resident 1 about altercation with Resident 6 and coordinated translation |
| Director of Nursing | DON | Provided root cause analysis and confirmed lack of monitoring during incidents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect residents from physical abuse and resident-to-resident altercations.
Complaint Details
The complaint investigation substantiated that Resident 1, Resident 2, and Resident 6 were involved in physical altercations resulting in injuries. The facility lacked adequate supervision in the dining room and nursing station areas during the incidents. Staff interviews confirmed insufficient monitoring and delayed intervention during resident altercations.
Findings
The facility failed to protect residents from physical abuse by not implementing adequate safety measures to prevent altercations among residents. Three residents (Resident 1, Resident 2, and Resident 6) experienced physical abuse during incidents involving aggressive behavior and altercations.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse by not implementing safety measures to prevent resident-to-resident altercations involving three residents. This resulted in physical injuries such as abrasions and cuts to the affected residents.
Report Facts
Skin injury size: 0.2
Skin injury size: 0.2
Incident date: Aug 26, 2023
Incident date: Sep 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Reported partial visual monitoring and delayed supervision during dining room altercation |
| Certified Nursing Assistant 4 | CNA | Observed and intervened in altercation between Resident 1 and Resident 6 |
| Registered Nurse 2 | RN | Interviewed regarding notification and investigation of altercation between Resident 1 and Resident 6 |
| Director of Nursing | DON | Provided root cause analysis and acknowledged lack of monitoring during resident altercations |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, safety, and regulatory requirements in the nursing facility.
Findings
The facility failed to ensure licensed nurses properly documented vital signs and medication administration for multiple residents, failed to post required oxygen safety signage, administered oxygen at incorrect flow rates, and did not document resident education regarding pneumococcal vaccination.
Deficiencies (4)
F 0658: Licensed nurses failed to obtain and document vital signs and medication administration as ordered for Residents 3, 6, 7, 8, and 9, risking inadequate care delivery.
F 0689: The facility failed to post no smoking/oxygen in use signs outside the rooms of Residents 2 and 10 receiving oxygen therapy, risking fire hazards.
F 0695: Resident 2 received oxygen at 3 LPM via nasal cannula despite an order for 2 LPM, risking oxygen toxicity and respiratory complications.
F 0883: The facility failed to document that Residents 3 and 6 or their representatives received education about pneumococcal vaccine benefits and risks prior to administration.
Report Facts
Medication administration missed documentation: 3
Vital signs monitoring missed documentation: 14
Oxygen flow rate order: 2
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding oxygen therapy and oxygen signage for Residents 2 and 10 |
| Director of Nursing | Director of Nursing | Interviewed regarding documentation gaps and oxygen administration policies |
| Infection Preventionist | Infection Preventionist | Interviewed regarding documentation and oxygen safety signage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to implement an effective pest control program, specifically the presence of flies inside the facility.
Complaint Details
The complaint investigation found the presence of flies inside the facility, verified by staff and a pest control technician. The issue was substantiated with observations and interviews confirming unsanitary conditions and potential health risks.
Findings
The facility failed to prevent flies from being inside, creating unsanitary living conditions that could increase health risks for residents, staff, and visitors. Observations and interviews confirmed the presence of flies in multiple areas, and the pest control technician verified flies at the main entrance.
Deficiencies (1)
F 0925: The facility failed to implement an effective pest control program by not preventing flies from being inside the facility, increasing the risk of unsanitary conditions. Flies were observed on glass doors and windows, and interviews confirmed the potential for flies to spread bacteria and cause harm.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 (RN 1) | Interviewed and observed fly presence in the facility. | |
| Infection Prevention Nurse (IP) | Interviewed about risks related to flies and infection. | |
| Director of Staff Development (DSD) | Verified presence of flies during observation. | |
| Pest Control Technician (PCT) | Provided information about fly reproduction and presence. |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nutritional and dietary requirements for residents, specifically focusing on adherence to prescribed renal diets.
Findings
The facility failed to follow the prescribed renal diet menus for three residents by serving mashed potatoes instead of buttered noodles, which could negatively impact residents' nutritional intake and medical status. Observations and interviews confirmed the incorrect food items were served, and no approved menu substitution for the noodles was documented.
Deficiencies (1)
F 0803: The facility failed to follow menus for residents on renal diets by serving mashed potatoes instead of buttered noodles, contrary to physician diet orders. This practice risks increasing sodium and potassium intake and may lead to decreased food intake and weight loss.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Observed missing noodles on renal diet trays and confirmed no preparation of noodles | |
| Director of Nursing | Confirmed renal trays had no noodles despite meal tickets indicating noodles and noted potential nutritional impact |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide pharmaceutical services as ordered for a sampled resident.
Complaint Details
The investigation was complaint-driven, focusing on medication administration for Resident 1. The complaint was substantiated with findings of missing medication administration documentation and confirmation from nursing staff and the Director of Nursing that medications were not administered on specified dates.
Findings
The facility failed to ensure medications were administered as ordered for one resident, with missing documentation indicating medications were not given on multiple dates. This posed potential risks of elevated blood pressure, heart rate, and seizures.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services including accurate acquiring, receiving, dispensing, and administering of drugs for one resident. Missing medication administration records indicated medications were not given as ordered, risking complications such as elevated blood pressure, heart rate, and seizures.
Report Facts
Missing medication administration dates: 7
Number of sampled residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 4 | LVN | Verified missing medication administration documentation for Resident 1 on 7/3/2023 shift |
| Licensed Vocational Nurse 5 | LVN | Verified missing medication administration documentation for Resident 1 on 7/23/2023 shift |
| Director of Nursing | DON | Confirmed medications were not administered on multiple dates due to missing documentation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 21, 2023
Visit Reason
The inspection was conducted following a complaint regarding the possession of a firearm by Resident 1 within the facility, which raised safety concerns for residents, visitors, and staff.
Complaint Details
The complaint investigation was triggered by the discovery of a loaded gun in Resident 1's possession on 7/18/2023. The investigation substantiated that the facility failed to properly inventory Resident 1's belongings, lacked signage prohibiting weapons, and did not adequately screen visitors or personal effects. Resident 2 requested a room transfer due to safety concerns. Police collected the weapon and bullets, and recommended enhanced security measures.
Findings
The facility failed to implement its admission agreement rights by not accounting for Resident 1's personal belongings, including a loaded gun found on 7/18/2023. The facility lacked proper signage prohibiting weapons and did not adequately screen visitors or personal effects, increasing risk of harm.
Deficiencies (3)
F 0564: The facility failed to inform residents of visitation rights and ensure equal visitation privileges. A loaded gun was found in possession of Resident 1, increasing risk of injury and death.
F 0689: The facility failed to provide a safe environment by not preventing possession of a firearm by Resident 1 and inadequate supervision, leading Resident 2 to request a room transfer for safety.
F 0842: The facility failed to safeguard resident-identifiable information and maintain accurate personal belongings records for Resident 1, who possessed a gun not accounted for in inventory.
Report Facts
Bullets collected: 7
Admission date Resident 1: Resident 1 admitted on 7/22/2020 (date given but not numeric only).
Admission date Resident 2: Resident 2 admitted on 11/29/2022 (date given but not numeric only).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant 1 | Certified Nurse Assistant | Reported finding the gun on Resident 1 on 7/18/2023. |
| Registered Nurse 1 | Registered Nurse | Confirmed Resident 1 was alert and had not left the facility since admission. |
| Licensed Vocational Nurse 3 | Licensed Vocational Nurse | Expressed concerns about the danger of a gun in the facility and visitor screening. |
| Social Services Director | Social Services Director | Discussed Resident 1's inventory issues and facility policies. |
| Director of Nursing | Director of Nursing | Reported that inventory screening update for residents had not been completed after finding the weapon. |
| Police Officer 1 | Police Officer | Collected the gun and bullets from Resident 1 and recommended security improvements. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted to investigate complaints related to the use and care of feeding tubes and infection control practices in the facility.
Complaint Details
The investigation was complaint-related, focusing on feeding tube care and infection control. The complaint was substantiated as deficiencies were found in labeling and changing feeding tube supplies and in infection prevention practices.
Findings
The facility failed to ensure feeding tube supplies were labeled with date and time and changed every 24 hours for three sampled residents, risking inaccurate feeding and bacterial contamination. Additionally, the facility failed to follow proper infection control procedures during feeding tube setup, risking infection transmission to residents.
Deficiencies (2)
F 0693: The facility failed to ensure feeding tube supplies were labeled with date and time and changed every 24 hours for three residents, risking inaccurate feeding and bacterial contamination.
F 0880: The facility failed to follow infection control procedures by not performing hand hygiene and changing gloves appropriately during feeding tube setup for one resident, placing the resident at risk of infection.
Report Facts
Residents affected: 3
Residents affected: 1
Feeding pump rate: 55
Feeding pump rate: 45
Feeding pump rate: 55
Flush volume: 30
Flush volume: 60
Flush volume: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 2 (LVN 2) | Interviewed and observed regarding feeding tube care and infection control deficiencies. | |
| Director of Nursing | Interviewed regarding feeding tube labeling and change procedures. | |
| Infection Preventionist Nurse (IPN) | Interviewed regarding infection prevention measures and hand hygiene practices. |
Inspection Report
Routine
Deficiencies: 16
Date: Jan 13, 2023
Visit Reason
Routine inspection of Alexandria Care Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, call light accessibility, advance directive documentation, notification of physician for resident refusal, care planning, accident prevention, continence care, nutritional monitoring, feeding tube labeling, respiratory care, pain management, nurse staffing posting, medication storage and labeling, food safety, and restorative nursing services.
Deficiencies (16)
F 0550: The facility failed to maintain residents' dignity and respect by staff standing over residents while feeding and not covering urinary drainage bags with privacy bags.
F 0558: The facility failed to ensure call lights were within reach for three residents, risking delayed assistance and potential harm.
F 0578: The facility failed to ensure current advance directives or acknowledgement forms were in the medical records for 20 of 40 sampled residents.
F 0580: The facility failed to notify the physician when Resident 106 refused to be weighed, risking delayed care.
F 0656: The facility failed to develop and implement a complete, individualized care plan for Resident 129, risking delayed care delivery.
F 0689: The facility failed to perform elopement risk assessment for Resident 7 and failed to follow smoking policy for Resident 103, risking resident safety.
F 0690: The facility failed to provide timely assistance and incontinence care for Residents 71 and 126, risking urinary tract infections and psychosocial harm.
F 0692: The facility failed to monitor and intervene for significant weight loss in Resident 152, resulting in unplanned 5.5% weight loss in one month.
F 0693: The facility failed to label gastrostomy tube feeding bottles and tubing with staff initials, date, and time for Residents 1, 7, and 42, risking infection and feeding errors.
F 0695: The facility failed to label nasal cannula and nebulizer tubing with date of change for Residents 74, 360, and 260, risking infection and respiratory distress.
F 0697: The facility failed to schedule a pain consultation appointment per physician order for Resident 14, risking inadequate pain management.
F 0732: The facility failed to post daily nurse staffing information for three days, risking lack of transparency for residents, staff, and visitors.
F 0755: The facility failed to have Lorazepam in the Emergency Medication Kit, risking delayed treatment of anxiety and continuity of care.
F 0761: The facility failed to label medications and glucometer quality control solution with open dates, risking administration of expired medications.
F 0812: The facility failed to label and date opened food containers, had out of date fruit punch, and stored food on the floor, risking foodborne illness.
F 0825: The facility failed to provide Restorative Nursing Assistant services as ordered for Resident 95, risking decline in range of motion and mobility.
Report Facts
Weight loss: 7
Pain level: 9
Norco doses: 24
Norco doses: 12
RNA staff count: 4
RNA missing days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Confirmed nasal cannula tubing not labeled with date/time for Resident 74 |
| LVN 4 | Licensed Vocational Nurse | Confirmed nebulizer tubing not dated for Resident 260 |
| RN 5 | Registered Nurse | Observed Lorazepam missing from Emergency Medication Kit |
| DSD | Director of Staff Development | Confirmed missing daily nurse staffing postings and RNA staffing shortages |
| DON | Director of Nursing | Confirmed missing pain consult appointment for Resident 14 and labeling deficiencies |
| RNA 1 | Restorative Nursing Assistant | Reported missing RNA documentation and staffing shortages |
| CNA 5 | Certified Nursing Assistant | Reported residents complaining of delayed assistance due to staff shortage |
| DSS | Dietary Services Supervisor | Reported unlabeled and out of date food items in kitchen |
| KDM | Kitchen District Manager | Confirmed policy on food labeling and safety |
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