Other·October 26, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated survey for complaint investigation. Complaint CA00577350 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 16282 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint CA00577350.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 10/23/2018 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sample LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents (Resident 1) received care, consistent with professional standards of practice, to promote healing of a Stage II pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure) and prevent the development of two new pressure ulcers. As a result, Resident 1' pressure ulcer to the tailbone area worsened to the point of requiring surgical intervention and Resident 1 developed pressure ulcers to the right and left buttocks. Findings: On 3/21/18, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint about Resident 1' quality of care. A review of the facility's actual census indicated Resident 1 no longer resided in the facility and was discharged on 7/27/17 to General Acute Care Hospital 1 (GACH 1) and did not return to the facility. According to the Admission Record, Resident 1 was initially admitted on 7/5/17 with the diagnoses including intertrochanteric fracture of left femur (broken left hip) status post-surgery to repair the fracture, muscle weakness, difficulty in walking, and dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of the Physician's Orders dated 7/5/17, included to provide Resident 1 regular/liberalized diet, weigh every Thursday on the day shift for four weeks, and give ferrous sulfate 325 milligrams (mg) as a supplement. A review of the Progress Notes dated 7/5/17, timed at 6 p.m., indicated an admission of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 for rehabilitation. The Braden Scale (used for predicting pressure sore risk) score was 16 (meaning the mild risk to develop pressure sores). Resident 1 had a surgical incision (cut) on the left hip (from the hip surgery). A review of the Progress Notes dated 7/5/17, timed at 10 p.m., indicated Resident 1 had Sacro-coccyx (tailbone area) Stage II pressure sore measuring 3.5 centimeters (cm) in length, 1.5 cm in width, 0.2 cm in depth. A review of the Care Plan developed on 7/6/17, for Resident 1's skin breakdown on the sacrococcyx, included in the interventions provide wound treatment as ordered, skin checks per policy, weekly skin assessment by the licensed nurse to include measurements and description of the wound status. A review of Physician's Order dated 7/7/17, indicated cleanse Resident 1's sacro-coccyx pressure sore with wound cleanser, pat dry, apply skin protectant and cover with Hydrocolloid dressing (advanced wound care product that is waterproof and self-adhering, making it easy to use and effective at maximizing healing) daily and as needed for 30 days. A review of the Progress Notes dated 7/7/17 indicated Resident 1 was alert with confusion, did not speak English and refused breakfast and lunch. Resident 1's family would bring traditional food (Resident 1's culture) to entice Resident 1 to eat more. A review of the Minimum Data Set (MDS standardized assessment and care-planning tool) dated 7/12/17, indicated Resident 1 could sometimes understand and be understood, required extensive assistance and one-person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physical assist with bed mobility, transfers, toilet use, eating, and personal hygiene, and weighed 140 pounds. A review of the Nutritional Assessment dated 7/17/17, indicated Resident 1 had poor intake and risk for weight changes/abnormal hydration related to dementia. Resident 1's intake was not meeting the nutritional needs. The Registered Dietitian (RD) recommended multivitamins with minerals for wound healing, add Peroneal® (medical food developed for the dietary management of wounds and conditions requiring supplemental protein) 30 milliliters (ml) for wound healing, house supplement daily with breakfast, and document the percentage consumed. Food preferences (ice cream, scrambled egg, cream soup, soy milk, and coffee with cream) were updated, the family verbalized Resident 1's choice to not having a feeding tube. The staff would continue to encourage meal and fluid intake based on Resident 1's tolerance. A review of the Care plan developed on 7/17/17 for Resident 1's nutritional risk related to weight loss and poor intake, included in the interventions encouraging food and fluid consumption, honoring food preferences, weighing as ordered and alert the RD and Physician if any significant weight loss or gain. The approaches did not include the use of pressure relieving devices (mattress and cushions). A review of the Skin Integrity Reports dated 7/13/17 and 7/19/17, indicated Resident 1 pressure sore size and status did not change since admission, 7/5/17. A review of the Weight Summary indicated on 7/19/17, Resident 1's weight was 121 pounds, a weight loss of 19 pounds in two weeks. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Progress Notes dated 7/19/17, at 12:43 p.m., indicated the nurse informed the Physician about Resident 1's weight loss, who recommended tube feeding and calorie count of food consumed for two days. A review of the Progress Notes dated 7/22 and 7/23/17, indicated Resident 1 was encouraged to eat, was noted not eating the facility's food and only small amounts of the food the family provided. The calorie count documentation was incomplete. A review of a Physician's Orders dated 7/24/17, indicated to give Resident 1 the appetite stimulant Menace and the antibiotic Keflex for surgical wound infection of the left hip. A review of the nursing notes indicated no evidence Resident 1's surgical infection was infected; there was no documentation of sign or symptoms of infection to the surgical wound. A review of the Progress Notes dated 7/25/17, at 7:02 p.m., indicated that a Certified Nursing Assistant (CNA) informed the licensed nurse that Resident 1 had right and left buttocks skin breakdown. The licensed nurse indicated the sacro-coccyx pressure sore was a deep tissue injury (DTI) measuring 5 cm in length by 4 cm in width. The left buttocks had Stage II pressure sore measuring 5 cm in length by 4 cm in width and a right buttocks Stage II measuring 5.5 cm in length by 5.5 cm in width and a right upper buttock Stage I (reddened area with no broken skin) measuring 3 cm by 6 cm. Resident 1 had pain on the three pressure sores. A review of the Care Plan for skin breakdown on the right and left buttocks dated 7/25/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated to continue with the 7/6/17, plan for skin breakdown of the sacro-coccyx. On 7/26/17, the Care Plan for the sacro-coccyx pressure sore was updated with interventions including multivitamins with minerals and ProHeal® as ordered, turn and reposition every two hours as needed. According to the Treatment Administration Record for 7/2017, Resident 1 refused the treatment on 7/9, 7/12, 7/15, 7/18, 7/21 and 7/23/17. There was no documentation on how many attempts staff made on the days Resident 1 refused treatment and if the nurses sought help from the family to get Resident 1's cooperation. A review of the Progress Notes indicated on 7/26/17, Resident 1's weight was noted to be 108.9 pounds. The family decided to have Resident 1 get a tube feeding and intravenous (IV) fluids for hydration. The nurses transferred Resident 1 to GACH 1 on the same day, 7/26/17 at 7 p.m. A review of GACH 1 Consultation Note dated 7/29/17, indicated Resident 1 presented with a pre-sacral area measuring 6 cm by 4 cm Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia [thin sheath of fibrous tissue enclosing a muscle or other organ], muscle, tendon, ligament, cartilage or bone) pressure ulcer. The ulcer had necrotic (dead) tissue which required surgical debridement (removal of death tissue) in the operating room under sedation and local anesthesia. Resident 1's Discharge Summary date 8/8/17, indicated final discharge diagnoses which included Stage 4 sacrococcygeal pressure ulcer, open wound on the left hip, dehydration, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and severe protein-calorie malnutrition. On 5/2/18, at 11 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 had poor dietary intake and did not like the facility's food. The DON was unable to explain why the licensed nurses did not promptly identify the deterioration of the sacro-coccyx pressure sore and the development of a right and left new pressure ulcers. On 6/8/18, at 1:48 p.m., during an interview, Resident 1's Family Member 1 (FM 1) stated the staff would not assist Resident 1 to eat or drink, and they would not turn and frequently reposition as requested by the family. Resident 1 was not provided an air mattress (pressure relieving device) despite the family's request. A review of the facility's policy titled, "Skin Integrity Management" revised on 11/28/16, indicated the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers. Manage treatment, and promote healing of all wounds; identify skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information; determine the need for support surface for bed and chair; review care plan weekly and revise as indicated; and document daily monitoring of ulcer site, with or without dressing. A review of the facility's policy for Nutrition/Hydration Management revised on 3/15/16, indicated the purpose of the policy was to provide safe and effective care to manage nutrition and hydration needs. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration. Include interventions for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056113 (X3) DATE SURVEY COMPLETED 09/28/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ALEXANDRIA CARE CENTER 1515 N Alexandria Ave Los Angeles, CA 90027 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents with functional difficulties which may affect the ability to eat or drink independently, observe oral consumption of meals, supplements, and snacks and complete the meal data collection sheet when ordered or indicated, and revise care plan as needed. Document percentage of food/fluid Intake on Meal Monitor Data Collection Sheet when ordered or recommended; and administer supplements. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HT5311 Facility ID: CA970000003 If continuation sheet 8 of 8