Other·November 17, 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 Department of Public Health during the investigation of four Facility Reported Incidents (FRIs) and one complaint during the Recertification Survey. FRI number CA00606706 FRI number CA00604634 FRI number CA00606709 FRI number CA00606438 FRI number CA00609736 Complaint number CA00515997 Representing the Department of Public Health: Surveyor ID No: 38700 Surveyor ID No: 36291 Surveyor ID No: 27679 Surveyor ID No: 36923 Four deficiencies were issued for CA00606706: Refer to F550, F558, F684 and F691. Two deficiencies were issued for CA00604634: Refer to F550, F558. One deficiency unrelated to the allegation was issued for CA00606709: Refer to F558. No deficiencies were issued for FRI CA00606438 and complaint CA00515997. Five deficiencies were issued for FRI number CA00609736: Refer to F600, F558, F656,

F684, F691. Total Population: 158 Sample Size: 50 Highest Severity and Scope : G The following complaints were investigated during the Recertification Survey 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: 985N11 Facility ID: CA970000003 If continuation sheet 1 of 144 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 10/05/2018 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

F550 Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 2 of 144 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 10/05/2018 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 the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: d. A review of the admission record indicated Resident 53 was admitted on October 17, 2017, with diagnoses including but not limited to, hypertension (high blood pressure), and pressure ulcer of sacral region (bedsore located on the lower back at the bottom the spine). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated July 24, 2018, indicated Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 53 required extensive assistance for dressing, toilet use and personal hygiene. The MDS indicated Resident 53 had one stage four pressure ulcer (full thickness tissue loss with exposed bone). On October 2, 2018 at 9:04 a.m., during a tour of the facility, Resident 53 stated she had been waiting for 30 minutes to have her diaper changed. Resident 53 stated, "I have a wound in my back and how am I supposed to keep it dry if no one comes to change my diaper". Resident 53 stated sitting on wet diaper made her feel "pretty bad". Resident 53 stated staff would come in the room, turn the call light off and would not ask her what she needed. While speaking to Resident 53 a staff member came in the room, turned off the light and told the resident she would get someone to help her. Resident 53 stated, "it is very sad, I feel neglected, I wonder if they think because I am old I don't fight back". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 3 of 144 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 10/05/2018 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 Resident 53's physician order dated April 19, 2018, indicated to give the resident Lasix (a mediation used to reduce extra fluid in the body and causes a person to urinate often) 20 milligram (mg) one time a day. On October 2, 2018 at approximately 10:15 a.m., Resident 53 was observed sitting on the wheelchair. Resident 53 stated she was still waiting for the diaper change and that no one has come in to help. A review of the facility policy and procedure titled "Residents Rights Under Federal Law" and revised on January 25, 2018, indicated to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and selfworth. Based on observation, interview, and record review, the facility failed to enhance residents' dignity and respect for four of 50 sampled residents (Residents 103, 60, 250, and 53) and for 4 of 7 alert residents who attended the Group Meeting by: 1. Failing to ensure Resident 103 would be assisted to the restroom when requested to prevent the resident from soiling his incontinence brief. 2. Failing to ensure the Dietary Department would not serve Resident 103 and 4 alert residents meal with plastic utensils (made of plastic). 3. Failing to ensure the facility staff would not leave Resident 60's uncovered, exposing her incontinence brief. 4. Failing to provide privacy for Resident 250 when he was disrobed from the waist down in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 4 of 144 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 10/05/2018 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 his room and visible from the hallway. 5. Failing to assist Resident 53 who had a pressure ulcer (skin injury) with changing her wet brief for over an hour and a half. These deficient practices had the potential to negatively affect Residents 103's and 53's dignity and self-worth and violated Resident 60's and 250's right to privacy and dignity which had the potential to result in embarrassment for the residents. Findings: a.1. A review of the admission record indicated Resident 103 was admitted to the facility on August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region, and abnormal gait and mobility. A review of the History and Physical report completed on August 6, 2018, indicated Resident 103 was awake and alert. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required total one person physical assistance with toilet use. A review of the Initial Nursing Assessment dated August 3, 2018, indicated Resident 103 was incontinent of bowel and bladder and was not on a toileting program. The nursing assessment did not indicate the type of Resident 103's urinary incontinence. On October 2, 2018 at 12:45 p.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 5 of 144 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 10/05/2018 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 observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated that about an hour ago, he was in the dining room and requested to use the bathroom; a nurse took him to the nursing station and left him there. Resident 103 stated that he was staring at the walls while trying to get someone's attention, but everyone was just walking by him. After a while, the Physical Therapist Assistant (PTA 1) asked him if he needed help and he responded he needed to use the restroom. Resident 103 stated that he thought PTA 1 would take him to the restroom, but instead took him back to his room and told the resident he would get someone to help him. Resident 103 stated that after about 30 minutes, he soiled himself and was currently still soiled. When asked how he felt about his concerns, resident stated that he felt sad and depressed. On October 2, 2018 at 1:06 p.m., during a follow-up interview, Resident 103 stated he was able to feel the urge to urinate and that incontinence care was not being provided timely. On October 2, 2018 at 3 p.m., during an interview, PTA 1 stated that Resident 103 was by the nursing station around lunch time and verbalized that he wanted to use the restroom. PTA 1 stated that he took Resident 103 back to his room and told him that he would notified the nurse. PTA 1 stated that he notified Certified Nursing Assistant 7 (CNA 7). On October 3, 2018 at 7:24 a.m., during an interview, CNA 2 stated that Resident 103 would sometimes feel the urge to urinate or have a bowel movement. CNA 2 stated that Resident 103 had episodes of continence and incontinence of bowel and bladder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 6 of 144 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 10/05/2018 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 On October 3, 2018 at 8:40 a.m., during an interview, CNA 7 stated that yesterday (October 2, 2018) around lunch time, Resident 103 was by door of his room, sitting in his wheelchair and was trying to wheel himself inside the room. CNA 7 stated that Resident 107 looked "upset"; when asked if he needed help, Resident 103 responded that he was in the dining room and had requested someone to take him to the restroom; a staff brought him back, but did not help him with his toileting needs. CNA 7 stated that when she went to assist Resident 103, the resident had already soiled himself. CNA 7 stated she spent some time trying to calm him down because he was pretty upset (crying). a.2. On October 2, 2018 at 12:45 p.m., during an observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. Resident 103 was eating lunch using a plastic spoon. During a concurrent interview, Resident 103 stated that the facility would sometimes run out of silverware and would serve residents with plastic utensils. Resident 103 stated it was not his preference to use plastic utensils and he was not supposed to eat with plastic utensils. On October 3, 2018 at 10:10 a.m., during the Group Meeting, four of seven residents in attendance stated the residents would sometimes be served meals with plastic utensils because the Dietary Department ran out of silverware. On October 4, 2018 at 4:33 p.m., during an interview, the Administrator of the facility stated the Dietary Department did not notify him that there were not enough silverware for the residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 7 of 144 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 10/05/2018 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 facility's revised policy dated September 1, 2013, titled "Treatment: Considerate and Respectful" indicated that the facility will promote care for patients in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality. b. A review of the admission record indicated Resident 60 was admitted to the facility on July 27, 2016, with diagnoses that included muscle weakness and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of the care plan revised on October 1, 2018, indicated Resident 60 was dependent for activities of daily living (ADL-basic self-care tasks an individual does on a day-to-day basis) care in dressing. The goal indicated Resident 60 will maintain highest capable level of ADL ability as evidenced by her ability to perform ADL. The care plan indicated to provide Resident 60 with extensive assistance for dressing. On October 2, 2018 at 9:05 a.m., during an observation, Resident 60 was lying in bed and sleeping. Resident 60 did not have any blanket, or clothes covering the lower part of her body (from the waist to toes). The privacy curtain and the door were opened. Resident 60's incontinence brief was exposed and was in the line of sight of people walking in the hallway. On October 2, 2018 at 9:23 a.m., during an interview, CNA 7 stated Resident 60's incontinence brief was not to be exposed and the resident should have been covered. CNA 7 was observed going into Resident 60's room and covered the resident with a sheet and blanket. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 8 of 144 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 10/05/2018 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 facility's revised policy dated September 1, 2013, titled "Treatment: Considerate and Respectful" indicated that the facility will promote care for patients in an environment that maintains or enhances each patient's dignity and respect in full recognition of his or her individuality. c. A review of the Resident 250's admission record dated 10/4/18 at 11:58 a.m., indicated the resident was admitted to the facility on 9/26/18, with diagnoses including left knee osteoarthritis (a type of joint disease that results from breakdown of joint cartilage and underlying bone), muscle weakness, and difficulty walking. During an observation on 10/2/18 at 10:50 a.m. from the hallway outside Resident 250's room door, Resident 250 was observed sitting in a shower chair wearing only a pajama top facing away from the open door. The privacy curtains were not closed and the resident's buttocks were visible through the openings in the shower chair. Licensed Vocational Nurse (LVN 8) and Certified Nurse Assistant (CNA 3) were observed in the room making the bed. During an interview with LVN 8, on 10/2/18 at 11:00 a.m., she stated "I should have closed the door for patient privacy." During an interview with Resident 250 with Family Member 1 present, on 10/2/18 at 11:05 a.m., the resident was alert and oriented to person, place, time, and situation. The resident spoke with clear speech and did not have difficulty understanding conversation. Resident 250 stated he just had knee surgery and would be at the facility for rehabilitation for about a week. The resident stated that the nursing care during his stay has been "Okay, they do their best." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 9 of 144 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 10/05/2018 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 During a Group Meeting on 10/3/18 at 10:00 a.m., Resident 250 stated, "I don't mind if people come into my room, as long as I am getting the help I need. I wish that the facility were more concerned about patient care instead of just worrying about what the Health Department thinks." A review of the facility policy and procedure titled "OPS209 Privacy Rights: Patient" dated 11/28/17, indicated "the patient has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes accommodations, medical treatment, written, telephone and electronic communications, personal care, visits and meetings of family and patient groups, but this does not require the Center to provide a private room for each patient." A review of the facility policy and procedure titled "OPS213 Treatment: Considerate and Respectful" dated September 1, 2013, indicated "1.8 Privacy: Maintain privacy of body including keeping patients sufficiently covered, such as with a robe, while being taken to areas outside their rooms such as bathing areas."

F558 SS=E Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 11/18/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: d. A review of the Resident Council minutes for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 10 of 144 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 10/05/2018 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 the months of July and August 2018, indicated the residents verbalized that the Certified Nursing Assistants would take 30 to 45 minutes to answer call lights. On October 3, 2018 from 10:10 a.m. to 11:10 a.m., during a Group Meeting, three out of seven residents in attendance stated that when they press the call light button to request for assistance, the CNAs would come inside the room, turn off the light, and say just a minute or I will get someone to help, and that person never would show up. The residents stated that they would press the call light again, the CNAs would turn off the light and no one would come for another 20 minutes. Five out seven residents in attendance stated that they felt the facility did not have enough staff to meet the needs of the residents. On October 5, 2018 at 11:20 a.m., during an interview, the Administrator of the facility stated that call lights response was a Quality Assessment and Assurance's focused area during the previous quarter, but not anymore because data collected from audits indicated that call light response time had improved. The Administrator stated that the audits conducted focused on call light response time, but did not focus on whether or not resident's needs were addressed after responding to call light. A review of the facility's revised policy dated October 1, 2012, indicated that residents will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly. e. A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in September 15, 2018, with diagnoses that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 11 of 144 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 10/05/2018 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 included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status (an operation that creates an opening for the large intestine, through the abdomen), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable-classify a disease as having reached a particular progression of the disease, due to coverage of wound bed by dead or non-viablecapable of surviving, tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. A review of the History and Physical (H&P) report completed on September 6, 2018, indicated that Resident 119 was alert and oriented. On October 2, 2018 at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff was ignoring him (resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, wound dressing, colostomy bag timely, and did not empty his colostomy bag. Resident 119 stated that the call light response during the night was "worse" because the nursing staff would sometimes acknowledge his needs and sometimes would answer the call light and tell FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 12 of 144 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 10/05/2018 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 him that they will notify his assigned nurse, but no one would show up. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad." f. A review of the admission record indicated Resident 139 was admitted into the facility on September 5, 2018, with diagnoses that included high blood pressure, heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), and anemia (lower-than-normal number of red blood cells or hemoglobin in the blood). A review of the History and Physical Report completed on August 8, 2018, indicated Resident 139 had the capacity to understand and make medical decisions. A review of the Minimum Data Set (a comprehensive assessment and care screening tool) dated September 12, 2018, indicated Resident 139 usually understood others and was usually able to make herself understood. The MDS also indicated Resident 139 required total assistance, one person physical assistance with toilet use and extensive assistance (two or more person assistance) with bed mobility. On October 2, 2018 at 9:24 a.m., during an observation, Resident 139 was sitting in her wheelchair, awake, and oriented to person and place. During a concurrent interview, Resident 139 stated that the call light responses during the night shift was 15 to 20 minutes and that sometimes, the nursing staff would not respond and address her needs (administration of pain medication), which did not make her feel good. g. A review of the admission record indicated Resident 92 was admitted into the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 13 of 144 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 10/05/2018 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 July 27, 2018, with diagnoses that included muscle weakness, difficulty in walking, and paraplegia (paralysis of the lower part of the body, including the legs). A review of the MDS dated August 3, 2018, indicated Resident 92 had intact cognition and required extensive one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. On October 2, 2018 at 3:27 p.m., during an interview, Resident 92 stated that the facility did not have enough CNAs to meet the needs of the residents. Resident 92 stated that night shift was worse in terms of staffing. Resident 92 stated that when he pressed the call light button to request for assistance, a nursing staff would come, turn off the light, respond that he/she was helping another resident and would be back, but no one would return until he had to press the call light again after 20 minutes. h. A review of the admission record indicated Resident 138 was admitted on June 29, 2016, with diagnoses that included high blood pressure and dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning). A review of the History and Physical report completed on October 14, 2017, indicated Resident 138 was awake, alert, and oriented to person and place. A review of the care plan initiated on June 9, 2016 and revised on October 5, 2018, indicated Resident 138 was dependent for activities of daily living (ADL-basic self-care tasks an individual does on a day-to-day basis) care in bathing, grooming, personal hygiene, dressing, bed mobility, eating, transfer, locomotion, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 14 of 144 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 10/05/2018 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 toileting related to recent mechanical fall. The goal indicated Resident 138 will maintain highest capable level of ADL ability as evidenced by her ability to perform ADL. The care plan interventions included: monitor conditions that may contribute to ADL decline, monitor for decline in ADL function, monitor for pain, evaluate and medicate for pain as appropriate, monitor for shortness of breath, fatigue and change of condition, provide cueing for safety, arrange resident environment as much as possible to facilitate ADL, provide resident with total assistance for bed mobility, and provide extensive assist for transfer. The care plan interventions did not indicate how to summon for help when the resident required assistance. On October 3, 2018 at 3:18 p.m., during an observation in the presence of Certified Nursing Assistant 6 (CNA 6), Resident 138 was lying in bed. The call light button was placed at the foot of the bed. During a concurrent interview, Resident 138 stated she was unable to reach the call light button. CNA 6 was observed taking the call light at the foot of the bed and giving it to the resident. i. A review of the admission record indicated Resident 38 was admitted on July 13, 2017, with diagnoses that included diabetes (high blood sugar), difficulty in walking, and pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral (low back) region. A review of the care plan revised on July 27, 2018, indicated Resident 38 was dependent for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, eating, transfer, locomotion, and toileting. The goal indicated Resident 38 will improve current level of function in ADL as evidenced by improved FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 15 of 144 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 10/05/2018 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 ADL scores. The care plan interventions indicated to provide the resident with total assistance for bed mobility, and provide total assistance for transfer. On October 2, 2018 at 8:53 a.m., during an observation, Resident 38 was lying in bed, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 38 stated that the call light response during the night was 15 to 30 minutes. j. A review of the admission record indicated Resident 103 was admitted to the facility on August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region, and abnormal gait and mobility. A review of the History and Physical report completed on August 6, 2018, indicated Resident 103 was awake and alert. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required total one person physical assistance with toilet use. The MDS indicated Resident 103 was always incontinent of urine and bowel. On October 2, 2018 at 12:45 p.m., during an observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated that about an hour ago, he was in the dining room and requested to use the bathroom; a nurse took him to the nursing station and left him there. Resident 103 stated that he was staring at the walls while trying to get someone's attention, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 16 of 144 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 10/05/2018 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 but everyone was just walking by him. After a while, the Physical Therapist Assistant (PTA 1) asked him if he needed help, and he responded he needed to use the restroom. Resident 103 stated that he thought the PTA 1 would take him to the restroom, but instead, took him back to his room and told the resident he would get someone to help him. Resident 103 stated that after about 30 minutes, he soiled himself and was currently still soiled. Resident 103 stated that the nursing staff had not changed his incontinence brief yet. When asked how he felt about his concerns, resident stated that he felt sad and depressed. During the same interview at 12:48 p.m., Resident 103 stated that he felt the facility did not have enough staff to meet the needs of the residents. k. On October 2, 2018 at 9:04 a.m., during a tour of the facility Resident 53 stated she had been waiting for 30 minutes to have her diaper changed. Resident 53 stated, "I have a wound in my back and how am I supposed to keep it dry if no one comes to change my diaper". Resident 53 stated sitting on wet diaper made her feel "pretty bad". Resident 53 stated staff would come in the room, turn the call light off and would not ask her what she needed. While speaking to Resident 53, a staff member came in the room, turned off the light and told the resident she would get someone to help her. Resident 53 stated, "It is very sad, I feel neglected, I wonder if they think because I am old I don't fight back". A review of the admission record indicated Resident 53 was admitted on October 17, 2017, with diagnoses including but not limited to hypertension (high blood pressure), and pressure ulcer of sacral region (bedsore located on the lower back at the bottom the spine). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 17 of 144 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 10/05/2018 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 Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated July 24, 2018 indicated Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 53 required extensive assistance for dressing, toilet use and personal hygiene. The MDS indicated Resident 53 had a stage four pressure ulcer (a bed sore with full thickness tissue loss with exposed bone). A review of the Resident 53's ADL (Activities of Daily Living) care plan indicated the resident required assistance for bathing, grooming, personal hygiene and toileting. The care plan indicated Resident 53's ADL care needs will be anticipated and met throughout the next review period. A review of Resident 53's physician order dated April 19, 2018 indicated to give the resident Lasix (a mediation used to reduce extra fluid in the body and causes a person to urinate often) 20 milligram (mg) one time a day. On October 2, 2018 at approximately 10:15, Resident 53 was observed sitting on the wheelchair. Resident 53 stated she was still waiting for the diaper change and that no one has come in to help. A review of the facility policy and procedure titled "Accommodation of Needs" and revised on November 28, 2016, indicated the resident has the right to reside and receive services in the center with reasonable accommodation of individual needs and preferences. Based on observation, interview, and record review, the facility failed to accommodate the needs of 10 of 50 sampled residents (Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 18 of 144 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 10/05/2018 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 76, 106, 252, 119, 139, 92, 103, 38, 138, and 53) and for 6 of seven residents in attendance at the Group Meeting by: 1. For Resident 76, the facility failed to provide the resident with a functional call light. This deficient practice had the potential to prevent Resident 76 from communicating her needs to the staff and placed the resident at higher risk for fall. 2. For Resident 106, the call light was observed out of reach of the resident. This deficient practice had the potential to prevent Resident 106 from communicating his needs to the staff. 3. For Resident 252, an observation was made of the resident not receiving assistance to get his urinal in a timely manner despite placing his call light on. This deficient practice had the potential to cause a hospice (a type of care and philosophy of care that focuses on seriously ill resident's pain and symptoms, and attending to their emotional and spiritual needs) resident unnecessary discomfort and distress. 4. Failing to ensure the call light was within reach and was answered promptly for Residents 119, 139, 92, 103, 38, and 138, and 5. Failing to ensure the call light was within reach and was answered promptly for 6 of seven alert residents attending the Group Meeting. These deficient practices had the potential to result in the residents being unable to summon health care workers for assistance and can FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 19 of 144 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 10/05/2018 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 lead to a delay in provision of necessary care and services. 6. Failing to ensure Resident 53 was assisted with changing her wet brief timely. This deficient practice had the potential to result in skin injuries and can lead to unnecessary discomfort for Resident 53. Findings: a. A review of Resident 76's admission record, dated 10/5/18 and timed 4:46 p.m., indicated the resident's primary language was not the predominantly spoken language of the facility staff. The resident was admitted to the facility on 5/6/18 with diagnoses including head injury, seizures, and a history of falling. A review of Resident 76's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 8/13/18, indicated the resident had adequate hearing and vision with the use of glasses and clear speech. The resident had difficulty communicating some works or finishing thoughts and misses part/intent of message, but comprehends most conversation and has severe cognitive impairment. A review of the MDS dated 8/13/18 indicated Resident 76 required extensive one person assistance for walking, dressing, toileting, personal hygiene, and bathing. Resident 76 required extensive two person assistance with bed mobility and transfers. The resident was always continent of bladder and bowel and was not on a training program for urinary or bowel continence. A review of Resident 76's care plan dated 5/6/18, titled "The resident has impaired FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 20 of 144 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 10/05/2018 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 communication as evidenced by CVA (cerebral vascular accident - stroke), and language/language barrier," had nursing interventions that included "place call bell within reach at all times." A review of Resident 76's care plan dated 5/6/18, titled "Resident is at risk for falls: CVA, Impaired mobility, history of fall," had nursing interventions that included "Place call light within reach while in bed or close proximity to the bed," and "Remind resident to use call light when attempting to ambulate or transfer." The care plan indicated Resident 76 had actual falls on 8/2/18, 9/10/18, 9/13/18, and 9/14/18. During an observation of call lights on 10/3/18 at 3:30 p.m., at Station 3, an attempt to activate the call light for Resident 76 did not turn on the hallway light signal. Maintenance Supervisor (MS), Administrator (ADM), and Maintenance Assistant (MA) were present and attempted to the fix the call light button to no avail. The call light button was replaced immediately and when activated, the hallway light signal turned on. During a concurrent interview on 10/3/18 at 3:30 p.m., the MA stated, "No one told me the call light wasn't working." During an interview with Resident 76 on 10/5/18 at 4:13 PM, with the translation assistance of the Activities Director (ACD), the resident stated, "When I am in my room and I need help, I press the button and wait for the nurse. I am not supposed to get out of bed until the nurse comes." The resident stated, "Sometimes when I press the button" but was unable to complete the sentence. A review of the facility policy and procedure titled "NSG101 Call Lights" dated March 1, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 21 of 144 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 10/05/2018 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 2016, indicated "All [facility] patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly." b. A review of Resident 106's admission record, dated 10/4/18 and timed 12:00 p.m., indicated the resident whose primary language was not the predominantly spoken language of the facility staff. The resident was initially admitted to the facility on 3/14/18, and had recently been readmitted from a general acute care hospital on 8/20/18. Resident 106's diagnoses included end stage renal disease (a condition where kidneys lose the ability to filter waste from your blood sufficiently) with dependence on renal dialysis (a treatment process that removes excess water and toxins from the body), Parkinson's disease (a chronic and progressive movement disorder), and amputation of the left leg above the knee. A review of Resident 106's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 8/27/18, indicated the resident was able to hear adequately and had clear speech, and was sometimes understandable (ability was limited to making concrete requests) and sometimes understood others (responded adequately to simple, direct communication only). Resident 106 required extensive one person physical assistance for bed mobility and dressing and was totally dependent on two person physical assistance for transfer, eating, toilet use, personal hygiene, and bathing. A review of Resident 106's care plan dated 9/4/18, titled "Resident is at risk for falls/injury due to functional limitations/impairment and cognitive loss," indicated nursing interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 22 of 144 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 10/05/2018 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 that included "Place call light within reach while in bed or close proximity to the bed" and "Remind resident to use call light when attempting to ambulate or transfer." During an observation on 10/2/18, at 7:45 a.m., Resident 106 was observed lying in bed. The resident's call light was on the ground by his bed, approximately 3 feet away from the head of Resident 106's bed. During an interview with Certified Nursing Assistant (CNA 5) on 10/2/18 at 8:15 a.m., he stated the call light "shouldn't' be on the floor; it should be by his bed." CNA 5 picked up the call light and placed it near Resident 106's hand. A review of the facility policy and procedure titled "NSG101 Call Lights" dated March 1, 2016, indicated "All [facility] patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly." c. A review of the Resident 252's admission record dated 10/5/18 and timed 4:53 p.m., indicated the resident whose primary language was not the predominantly spoken language of the facility staff. The resident was admitted to the facility on 9/29/18, with diagnoses that included malignant neoplasm of the colon (cancer of the large intestine), cerebral infarction (stroke), chronic kidney disease (a condition that occurs when the kidneys don't work as well as they should to filter waste, toxins and excess fluid from the body). A review of Resident 252's initial nursing assessment dated 9/29/18, and timed 9:06 p.m., indicated the resident was alert, oriented to person and place and had moderate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 23 of 144 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 10/05/2018 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 alteration in judgment and insight. The resident had adequate ability to hear, adequate ability to see with glasses and clear speech. Resident 252 had slightly limited mobility and needed limited assistance to change position and was confined to bed. The resident was also receiving a diuretic (a medication that promotes the increased production of urine). A review of Resident 252's care plan dated 9/29/18, titled "Resident has actual skin breakdown," indicated nursing interventions that included "provide peri care / incontinence care as needed." A review of Resident 252's care plan, dated 10/1/18, titled "Pt/Resident will be comfortable throughout the end of the journey, " indicated nursing interventions that included "Assess for pain, restlessness, agitation, constipation, and other symptoms of discomfort. Medicate as ordered and evaluate effectiveness. Provided non-pharmacological approaches to aide in decreasing discomfort." During an initial tour on 10/2/18 at 7:45 a.m., Resident 252 was observed lying in his bed with his privacy curtain drawn. A urinal was on the dresser behind the resident's head, and his bedside curtain was pulled which obstructed the resident's view of the door. The resident stated, "I need a urinal so I can pee" and pressed the call light. The call light indicator outside the room door was turned on, but there was no indicator within view of the resident, in order to know that the call light was on, nor that it was Resident 252 who had pressed the call light. At 10/2/18 at 7:47 a.m., Licensed Vocational Nurse (LVN 2) turned off the call light using the switch by the door, came partially into the room and asked Resident 252's roommate, Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 24 of 144 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 10/05/2018 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 96, if he needed any help. LVN 2 did not speak in a language Resident 252 understood. Resident 96 and Resident 252's language is different from the predominantly spoken language of the facility staff. Resident 96 pointed at the television. LVN 2 turned on the television and left room, but did not ask the other two residents (Resident 252 and Resident 106) if they needed assistance. At 10/2/18 at 7:50 a.m., during an interview with LVN 2, she stated, "He just wanted help with his television" and walked away from the room. At 10/2/18 at 8:15 a.m. Certified Nursing Assistant (CNA 4) went into Resident 252's room to pick up the breakfast trays. When CNA 4 went around the curtain to Resident 252's bed, the resident asked CNA 4 in to help him get his urinal. CNA 4 assisted the resident and kept the bedside curtain drawn for privacy. During an interview with LVN 6 on 10/05/18 at 3:35 p.m., she stated that the call lights do not indicate which resident had pressed the call light, but "when the call light is on, there's no way to see who has the problem. So I will check in with everyone in the room. I don't speak very much (Resident 252's native language), so if I can't understand the problem, I will get a translator." A review of the facility policy and procedure titled "NSG101 Call Lights" dated 10/01/12, indicated "All (facility) patients will have a call light or alternative communication device within their reach at all times when unattended. Staff will respond to call lights and communication devices promptly."

F565 SS=B Resident/Family Group and Response CFR(s): 483.10(f)(5)(i)-(iv)(6)(7) FORM CMS-2567(02-99) Previous Versions Obsolete

F565 Event ID: 985N11 11/05/2018 Facility ID: CA970000003 If continuation sheet 25 of 144 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 10/05/2018 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 §483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to inform four of 50 sampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 26 of 144 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 10/05/2018 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 (Residents 53, 85, 96, and 250), of the Resident Council Meetings, which resulted in the residents feeling like they were excluded from the meeting discussions. Findings: During a Group Meeting on 10/3/18 at 10:00 a.m., in the Station 2 Lounge, Residents 53, 85, 96 and 250, stated they did not know the Resident Council met every month. Resident 85 stated, "I think they don't invite me because they know I will complain a lot." Resident 250 stated, "It would have been nice if they had told me from the beginning that there was this type of meeting." A review of Resident 96's admission record dated 10/5/18, and timed 1:42 p.m., indicated the resident was an 84 year old male, whose primary language was not the predominantly spoken language of the facility staff. Resident 96 was admitted on 2/7/18 and his diagnoses included respiratory failure, congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), and difficulty in walking. A review of Resident 96's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 8/14/18, indicated the resident had adequate hearing, adequate vision with glasses, and had clear speech. Resident 96 was able to express ideas and wants, to understand verbal content with clear comprehension, and had no cognitive impairment. A review of Resident 250's admission record dated 10/4/18, and timed 11:58 a.m., indicated the resident was an 85 year old man who was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 27 of 144 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 10/05/2018 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 admitted to the facility on 9/26/18, with diagnoses including left knee osteoarthritis (a type of joint disease that results from breakdown of joint cartilage and underlying bone), muscle weakness, and difficulty walking. During an interview with Resident 250 with Family Member 1 present on 10/2/18 at 11:05 a.m., the resident was alert and oriented to person, place, time, and situation. The resident spoke with clear speech and did not have difficulty understanding conversation. Resident 250 stated he just had knee surgery and would be at the facility for rehabilitation for about a week.

F574 SS=B Required Notices and Contact Information CFR(s): 483.10(g)(4)(i)-(vi)

F574 11/05/2018 §483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 28 of 144 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 10/05/2018 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 protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) (iii) Information regarding Medicare and Medicaid eligibility and coverage; (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; (v) Contact information for the Medicaid Fraud Control Unit; and (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 29 of 144 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 10/05/2018 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 directives requirements and requests for information regarding returning to the community. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure residents received information and contact information regarding the State Long-Term Care Ombudsman program for 6 out of seven residents in attendance during a Group Meeting. This deficient practice violated the residents' rights to be informed of the State Long-Term Care Ombudsman program (an advocacy program for residents). Findings: On October 3, 2018 at 10:10 a.m., during a Group Meeting, six out of seven residents in attendance stated that they did not receive any information regarding the State Long-Term Care Ombudsman program. The residents stated they did not know the role of an Ombudsman. On October 5, 2018 at 2:40 p.m., during a general observation of the facility in the presence of the Activity Director (ACD), one Ombudsman poster was noted in the Main Dining Room. There were no other contact information posters regarding Ombudsman available in prominent (standing out so as to be seen easily) areas. The ACD was unable to provide documented evidence each resident received a written description of the Ombudsman contact information.

F580 SS=D Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15) FORM CMS-2567(02-99) Previous Versions Obsolete

F580 Event ID: 985N11 11/05/2018 Facility ID: CA970000003 If continuation sheet 30 of 144 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 10/05/2018 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 §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is(A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 31 of 144 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 10/05/2018 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 including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c) (9). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to notify the family and the physician regarding a change of condition for one of 50 sample residents (Resident 63) by failing to: 1. Notify Resident 63's responsible party when the resident fell on May 13, 2018. 2. Notify Resident 63's physician when the resident complained of left arm pain during RNA exercises on October 3, 2018. Findings: a. On October 2, 2018 at 8:36 a.m. during a tour of the facility Resident 63 was observed sitting in a wheelchair next to the bed. Resident 63 had one landing pad on the side the bed closest to the door, no landing pad on the other side of the bed closer to the wall. A review of the admission record indicated Resident 63 was admitted on April 27, 2018, with diagnoses including but not limited to hyperlipidemia (high cholesterol) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018, indicated Resident 63's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 32 of 144 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 10/05/2018 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 The MDS indicated Resident 63 required extensive assistance for moving in bed, transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of Resident 63's SBAR Communication Form (Situation, Background, Assessment and Recommendation - a communication tool) dated May 13, 2018, indicated the resident fell. The section of the SBAR form indicating "Name of the Family/Health Care Agent Notified" was blank. On October 4, 2018 at 11:14 a.m., during a concurrent record review and interview, Registered Nurse 4 (RN 4) stated could not find any documentation in Resident 63's medical record indicating the responsible party was notified of the residents fall. RN 4 stated the licensed nurse should have notified Resident 63's responsible party. A review of the facility policy and procedure titled "Change in Condition: Notification of" effective on November 28, 2016, indicated the facility must immediately notify consistent with his/her authority, the patients' health care decision maker where there is a significant change in the patient's physical, mental, or psychosocial status. b. A review of the "Change in Condition Evaluation" dated October 3, 2018, indicated Resident 63 had another fall and was found sitting near the foot of the bed. On October 4, 2018 at 10:47 a.m., during observation of the RNA (Restorative Nursing Assistant) exercises, Resident 63 began moaning and complained of pain when the RNA attempted to lift his left arm up above his head. RNA 1 stated Resident 63 never complained of left arm pain before. RNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 33 of 144 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 10/05/2018 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 stopped performing the exercises and informed the charge nurse. On October 4, 2018 at 3:13 p.m., RNA 1 returned and began performing PROM exercises on Resident 63 left arm. Resident 63 complained of left elbow pain when RNA 1 attempted to lift his left arm above his head. Resident 63 moaned and grabbed his elbow. RNA 1 stated this had never happened before and that Resident 63, always participated and this was not normal. RNA 1 stopped performing the exercise. On October 5, 2018 at 7:13 a.m., during a concurrent record review and interview, Registered Nurse 4 (RN 4) stated could not find any nursing documentation regarding Resident 63's elbow pain. RN 4 stated she could not find any change of condition documentation in Resident 63 medical record. On October 5, 2018 at 7:25 a.m., during an interview, Licensed Vocational Nurse 12 (LVN 12) stated RNA 1 did inform her twice that the resident complained of left elbow pain. LVN 12 stated she assessed the resident and gave Tylenol. LVN 12 stated she did not call the physician because there was no redness and no swelling on Resident 63's elbow. LVN 12 agreed the pain was new and that Resident 63 always participated in the RNA exercise. LVN 12 stated she was aware that Resident 63 had a fall the night before. On October 5, 2018 at 7:37 a.m., during an interview RN 4 stated the physician should have been notified of the left elbow pain, since Resident 63 fell the night before was not able to perform PROM exercises. A review of the facility policy and procedure titled "Physician/Advanced Practice Provider FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 34 of 144 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 10/05/2018 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 (APP) Notification" revised on March 15, 2016, indicated upon identification of a patient who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observation and data collection and report to physician/advanced practice provider.

F585 SS=E Grievances CFR(s): 483.10(j)(1)-(4)

F585 11/02/2018 §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 35 of 144 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 10/05/2018 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 (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 36 of 144 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 10/05/2018 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 summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to promptly address the grievance of one of 50 sampled resident (Resident 85). This deficient practice violated the resident's rights and placed the resident at risk for further physical and mental distress. Findings: On October 3, 2018 at 10:10 a.m., during the Group Meeting Resident 85 stated most staff treat him with dignity except for Certified Nursing Assistant 9 (CNA 9). Resident 85 stated about a month and half ago CNA 9 kept touching his PICC (a thin, soft, tube that is inserted into a vein in the arm and tip of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 37 of 144 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 10/05/2018 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 tube is positioned in a large vein that carries blood into the heart. It is often used for longterm antibiotic treatment, nutrition or medications and for blood draw) line area and that was very painful. Resident 85 stated this morning CNA 9 came back to his room even though he had told the licensed staff he did not want her services. A review of the admission record indicated Resident 85 was admitted on July 21, 2017, with diagnoses including but not limited to, diabetes mellitus (high blood sugar) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated August 15, 2018, indicated Resident 85's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. The MDS indicated Resident 85 required extensive assistance for moving in bed, transferring from bed to chair, toilet use and personal hygiene. On October 3, 2018 at 12:35 p.m., during an interview, Resident 85 stated CNA 9 would not listen and kept poking at his PICC line area, after he told her not to and that it was very painful. Resident 85 stated CNA 9 was laughing while poking at the PICC line site. Resident 85 stated he informed the Registered Nurse (RN) supervisor the day the incident happened. Resident 85 stated, "today they sneaked her in here, knowing I don't want her to work with me". On October 3, 2018 at 1:03 p.m., during an interview, Licensed Vocational Nurse 13 (LVN 13) stated about three weeks ago, Resident 85 informed her that CNA 9 did not listen to him and he was very upset about something. LVN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 38 of 144 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 10/05/2018 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 13 stated Resident 85 did not give her details about what happened. On October 5, 2018 at 9:44 a.m., during an interview, the Administrator (ADM) stated CNA 9 told him she accidentally touched Resident 85's arm and knew she was not supposed to come back to Resident 85's room. The ADM stated LVN 13 told him she was aware Resident 85 did not want CNA 9 services. The ADM stated LVN 13 told him she did send CNA 9 to the residents room, but she was not going to touch the resident. The ADM stated the staff should have respected the resident's preference of not being assigned to CNA 9. On October 5, 2018 at 10:52 a.m., during an interview, Social Worker 1 (SW 1) stated she could not find any grievance form regarding the incident between CNA 9 and Resident 85. SW 1 stated the staff should have filled out a grievance form and addressed the problem when it happened. A review of the facility policy and procedure titled "Grievance/Concern" and revised on March 1, 2018, indicated all residents and/or their representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document and follow up on all formal concerns and grievances registered by any resident or representative. Social services personnel will serve as patient advocates in the grievance/concern process.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 11/05/2018 §483.12 Freedom from Abuse, Neglect, and Exploitation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 39 of 144 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 10/05/2018 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 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three of 50 sampled residents (Residents 119, 103 and 139) were free of neglect (failure to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish (mental suffering), or emotional distress) and rough handling by: 1. Failing to provide wound dressing changes on an as needed basis and as requested by Resident 119 for 25 days (from September 10, 2018 to October 5, 2018), when the wound dressing was saturated with drainage, to prevent irritation to the surrounding skin and provide comfort to the resident. 2. Failing to provide colostomy (an opening into the large intestine, through the abdomen) care timely when requested by Resident 119. 3. Failing to implement the facility's policy and procedure on Abuse Prohibition by not conducting thorough investigation of allegations of neglect made by Resident 119, regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 40 of 144 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 10/05/2018 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 provision of care for the resident's wound dressings and providing colostomy care. 4. Failing to report allegations of neglect in provision of care made by Resident 119 to the Abuse Prevention Coordinator timely. 5. Failing to implement the facility's policy and procedure on Grievance/Concern, by not addressing, not investigating, not taking corrective actions, and not resolving grievances voiced by Resident 119. 6. Failing to ensure Social Service Director (SSD 1) would promote and protect Resident 119's psychological well-being and right to be free from neglect in provision of necessary care. 7. Failing to ensure the nursing staff would attend to Residents 119, 103, and 139's needs (changing/emptying colostomy bag-a container placed on the abdomen over a the colostomy site for discharge of bowel movements, changing incontinence brief, assistance to go to the restroom, toileting needs, incontinence care) timely and would not turn off the call light without addressing the residents' needs. 8. Failing to ensure Resident 119 was free from rough handling during care and during wound treatment and failing to ensure Residents 103, and 139 would be free from rough handling. 9. Failing to ensure Resident 103 would be assisted to the restroom when requested to prevent the resident from soiling his incontinence brief. As a result, Resident 119 felt sad, neglected, and was subjected to mental anguish and distress as evidenced by crying, resident's verbalization of wanting to leave the facility due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 41 of 144 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 10/05/2018 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 to unmet necessary wound care and colostomy care. These deficient practices also placed Resident 119 at risk for unnecessary skin irritation and can lead to further discomfort. These deficient practices also resulted in Resident 103 experiencing preventable incontinence episodes, which could lead to embarrassment, and Residents 119, 103, and 109 experiencing rough handling, which could result in physical injuries and affect the psychosocial well-being of the residents. These deficient practices also had the potential to affect 157 residents currently in the facility. Findings: a. A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted on September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status (an operation that creates an opening for the large intestine, through the abdomen), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable-a classification of the particular stage reached by a progressive disease, due to coverage of wound bed by dead or non-viablenot capable of healing, tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility (movement while in bed), transfer (movement from one surface to another including bed to chair), toilet use and personal hygiene. The MDS indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 42 of 144 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 10/05/2018 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 119 had an ostomy (an artificial opening in an organ of the body) and two unstageable pressure ulcers measuring 8 centimeters (cm) length by 5 cm width. A review of the History and Physical (H&Pinformation about a resident's medical past and examination findings) report completed on September 6, 2018, indicated Resident 119 was alert and oriented. Resident 119 was admitted with diagnoses of metastatic colon cancer (spread of cancer cells from initial site of the disease to another part of the body), to right buttock and to lungs. The physical examination section indicated right buttock metastatic ulcer (indurated- a localized hardening of soft tissue of the body that becomes firm/hard). A review of Resident 119's care plan initiated on August 28, 2018, and revised on September 4, 2018, indicated the resident had altered skin breakdown related to recent surgery, limited mobility, right inferior (lower in place or position) pressure injury unstageable, right superior (a higher place or position) pressure injury unstageable, and under scrotal area pressure injury unstageable. The care plan goal indicated the wound will remain free from signs and symptoms of infection for 14 days and the resident's wound will heal as evidenced by decrease in size, absence of erythema (abnormal redness of the skin) and drainage, and presence of granulation (a grainy surface as part of the healing process) for 14 days. The care plan interventions included: 1. Apply barrier cream with each cleansing 2. Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to physician as indicated 3. Monitor for effectiveness and/or side effects of medication (used to treat pressure injury) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 43 of 144 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 10/05/2018 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 4. Monitor for verbal and nonverbal signs of pain related to wound or wound treatment 5. Obtain dietitian consult as needed/ordered 6. Provide pericare (rectal, urinary and genital area) and /incontinence (any accidental or involuntary loss of urine from the bladder or bowel movement) as needed. A review of the care plan initiated on September 10, 2018, indicated Resident 119 was incontinent of bowel (any accidental or involuntary loss of bowel movements)and was unable to physically participate in a retraining program due to colostomy status. The care plan goal indicated Resident 119 will have incontinence care met by staff to maintain dignity and comfort and to prevent incontinence related complication. The care plan interventions included: apply moisture barrier to perianal (around the rectum) and perineal (urinary and genital area) as indicated, assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, and use absorbent product as needed. The care plan did not address necessary care specific to Resident 119's colostomy care. A review of the Grievance/Concern Form indicated Resident 119 filed a grievance on September 10, 2018, indicating that his wound dressing was not being changed during the second (3 p.m. to 11 p.m.) and third (11 p.m. to 7 a.m.) shifts. The investigation section indicated that the charge nurse was interviewed and that the charge nurse stated Resident 119's dressing was changed. The Resolution of Grievance/Concern section indicated that Resident 119 was informed that the charge nurse changed the dressing and that according to the charge nurse, the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 44 of 144 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 10/05/2018 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 forgot. Resident 119's Grievance/Concern Form dated September 10, 2018, did not include information as per the facility's policy and procedure for completion as follows: 1. The date the alleged incident occurred 2. The name of the alleged nursing staff involved. 3. Documentation of a thorough investigation; 4. How Resident 119's grievance was resolved; 5. Action plan to prevent further occurrence; 6. Protection of Resident 119 during the investigation; 7. Monitoring of Resident 119's feelings about the incidents; and 8. Corrective actions that were taken. A review of Resident 119's physician orders indicated to provide with the following wound treatments: 1. Right inferior buttock pressure injury (wound), right superior buttock pressure injury, and under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment (a remedy used to help the healing of skin ulcers), cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 15, 2018 with end date of September 29, 2018. 2. Right inferior buttock pressure injury (wound), right superior buttock pressure injury, and under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 29, 2018. 3. Monitor wound sites (right inferior buttock, right superior buttock, under scrotal area) daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 45 of 144 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 10/05/2018 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 for status of surrounding tissue and wound pain. Monitor for status of dressing (s), if applicable additional documentation in the nursing notes if needed, every shift. A review of the Resident 119's Treatment Administration Record (TAR) from August 28, 2018 to October 5, 2018, did not indicate that the nursing staff provided wound care/dressing changes as needed. A review of Resident 119's Wound Evaluation and Management Summary dated October 2, 2018, indicated the resident was oriented to person, place, time, and situation. The focused wound exam section indicated the following: 1. Burn Wound (radiation burn, a skin condition from treatment of disease, using X-rays or similar forms of radiation, per Resident 119) of the right superior buttock, wound size: 15 cm length by 11 cm width by 1 cm depth, surface area: 165.00 square centimeter, exudates (a liquid produced by the body in response to tissue damage): Moderate serous (the liquid part of blood), slough (dead tissue-including biofilm, a collection of microorganisms that can grow on many different surfaces): 30 percent (%), Granulation tissue: 70 %, wound progress: deteriorated. 2. Unstageable Deep Tissue Injury (DTI-a pressure-related injury to subcutaneous tissues under intact skin), wound size: 5 cm length by 3 cm width by 0.5 cm depth, surface area: 15.00 square centimeter, exudates: Moderate serous, slough (including biofilm): 20 %, Granulation tissue (healing surface of a wound): 80 %, wound progress: No change. On October 2, 2018 at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 46 of 144 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 10/05/2018 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 time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff were ignoring him (the resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, wound dressing, colostomy bag timely, and did not empty his colostomy bag. Resident 119 stated that he was tired of asking the nursing staff to perform those tasks, because it made him feel like a child. Resident 119 stated that he sometimes emptied his colostomy bag because some nursing staff did not want to empty it. Resident 119 stated that the nursing staff (assigned after 3 p.m.) did not want to change his wound dressing and that he notified (on an unspecified date) the social worker and the "social worker helper," who stated they will look into it and take care of the concern. Resident 119 stated that he notified Licensed Vocational Nurse 7 (LVN 7), who told the resident to "insist" that the nursing staff assigned after 3 p.m. change his wound dressing in the evening. Resident 119 stated that sometimes, the wound dressing would be saturated with drainage and that he would remove the "cushion- spongy part of the dressing" and change the incontinence brief (soiled by drainage). Resident 119 stated that when the wound dressing would become saturated with drainage, the drainage would go on the surrounding skin and irritate the skin; the resident would have to get a small towel and wipe the skin frequently until the morning shift. Even the incontinence brief would be wet from the wound drainage. Resident 119 stated that the call light response during the night was "worse" because the nursing staff would sometimes respond and acknowledge his needs and sometimes would answer the call light and tell him that they will notify his assigned nurse, but no one would show up. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 47 of 144 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 10/05/2018 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 119 stated that LVN 8 was one of the nurses that did not want to change his wound dressing. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad" because he had been residing in the facility for almost two months (admitted in August 2018), and since talking to the LVN 7 and the social workers about the situation (not having his wound dressing changed during the evening), things had not gotten any better. On October 2, 2018 at 12:19 p.m., during an interview, LVN 7 stated that Resident 119 reported to him twice, the first or 2 week of the resident's admission (last week of August 2018 or first week of September 2018), that his wound dressing was saturated with drainage and that the nurses during the evening/night shifts did not change his the dressing. LVN 7 stated that he notified the charge nurse (could not remember the name of the charge nurse) of Resident 119's complaint when the resident reported the concerns. LVN 7 stated that prior to changing Resident 119's wound dressing in the morning, the wound dressing would be saturated with drainage, which would lead the incontinence brief to be soiled as well. LVN 7 stated that Resident 119 emptied his colostomy bag because the resident knew how to care for his colostomy and preferred to care for it on his own. On October 2, 2018 at 2:55 p.m., during an interview, the Social Service Director (SSD) stated that the facility's procedure was to complete a grievance form whenever a resident filed a grievance (verbal or written). The grievance form would be given to the Social Service Department, which would assign the grievance to the appropriate discipline for resolution. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 48 of 144 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 10/05/2018 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 On October 3, 2018 at 7:15 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated that last week (could not remember the specific date), Resident 119 verbalized to her that the nursing staff did not change his wound dressing in the afternoon. CNA 2 stated that she notified LVN 6, who went to the resident's room and changed the resident's wound dressing. CNA 2 stated that Resident 119 had not verbalized he was depressed or sad, but CNA 2 could tell on the resident's face that he was sad (could not give specific details). On October 3, 2018 at 8:17 a.m., during an interview, LVN 6 stated that Resident 119 reported to her that his wound dressing was not being changed, which prompted LVN 6 to complete the grievance form on September 10, 2018. LVN 6 stated that Resident 119's wound had a lot of drainage. LVN 6 stated that LVN 7 had not reported to her that Resident 119 had complained in the past that his wound dressing was not being changed. On October 3, 2018 at 8:57 a.m., during an interview, the Quality Assurance Nurse (QA Nurse) stated she was responsible for investigating the grievance filed by Resident 119 on September 10, 2018. The QA Nurse stated that she interviewed LVN 5 and LVN 9, who stated that Resident 119 was able to verbalize when his wound dressing needed to be changed. The QA Nurse stated that LVN 9 stated Resident 119's wound dressing was changed on September 9, 2018, during the 3 p.m. to 11 p.m. shift and that the resident probably forgot his dressing was changed. The QA nurse stated that she informed Resident 119 that LVN 9 changed his dressing. The QA Nurse stated that during the investigation, Resident 119's clinical record indicated that the wound dressing had been changed on September 9, 2018, during the 3 p.m. to 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 49 of 144 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 10/05/2018 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 p.m. shift. However at 9:24 p.m., during a follow-up interview, the QA Nurse stated she was unable to provide documented evidence the licensed nursing staff provided wound care/wound dressing change to Resident 119's wound areas (right inferior and superior buttock, under scrotal area) on September 9, 2018, in August 2018, and/or September 2018, during the 3 p.m. to 11 p.m. and/or 11 p.m. to 7 a.m. shift. On October 4, 2018 at 9:28 a.m., during an interview, LVN 7 stated that he did not document Resident 119's concern (wound dressing not being changed as verbalized by the resident the first week after admission) because the charge nurses are responsible for documenting any concerns. LVN 7 stated that he notified the charge nurse and the social service department on an unspecified date. On October 4, 2018 at 10:37 a.m., during an observation, Resident 119 was lying in bed and LVN 6 was at the bedside administering (giving) medications. During a concurrent interview, Resident 119 stated that sometimes, he would change his colostomy bag and that when he asked some nurses to perform that task, they did not want to do it. Resident 119 stated that he did not receive any education/training from the facility staff of how to care for the colostomy. After Resident 119's statement, LVN 6, who was present during the interview, stated that it was the first time she was made aware that Resident 119, sometimes performed his own colostomy care. On October 4, 2018 at 12:07 p.m., during an interview, LVN 7 stated that Resident 119 told him (about the second week after admissionSeptember 5 to12, 2018), that he changed his own colostomy bag. LVN 7 stated that he did not notify anyone and did not document, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 50 of 144 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 10/05/2018 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 because he assumed the nurses knew Resident 119 was changing his own colostomy bag and performing colostomy care. LVN 7 reviewed Resident 119's care plan for bowel incontinence and stated that it did not address how to care for the resident's colostomy. On October 5, 2018 at 8:45 a.m., during wound care observation, LVN 7 removed the right buttock dressing, which was saturated with serous sanguineous (containing both blood and the liquid part of blood) drainage. The wound was hard and there was a strong, foul odor coming from the wound. The periwound (the skin surrounding an injury) was macerated (occurs when skin is in contact with moisture for too long, often associated with improper wound care) with a grayish color and the wound had yellowish and granulated (healthy) tissues. LVN 7 measured the right buttock wound and stated that the dimensions were 12 cm length by 12 cm width. LVN 7 cleansed the wound with a cleansing solution (spray), patted dry, applied Santyl, and covered the wound with a dry dressing. LVN 7 performed the same wound care treatment to Resident 119's under the scrotal wound area. Resident 119's colostomy bag was full` and was leaking. On October 5, 2018 at 9 a.m., during an interview in the presence of the Administrator of the facility, Resident 119 stated that he asked LVN 10 to change his wound dressing four times yesterday (on October 4, 2018) in the evening, but LVN 10 kept saying she was busy and would be back. Resident 119 stated that LVN 10 sent LVN 5 to perform his dressing change, but he (the resident) refused, because LVN 5 does not use the proper technique (uses a towel and water from the restroom, instead of gauze and cleaning solution) to change the dressing. Resident 119 stated that the towel was rough on his wound. Resident 119 stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 51 of 144 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 10/05/2018 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 LVN 10 did not want to empty and/or change his colostomy bag. Resident 119 stated that he would change his incontinence brief because of the drainage from the wound soiled the brief and would change and/or empty his colostomy bag, because some people did not want to do it. Resident 119 stated the first week he was admitted into the facility (August 28, 2018 to September 4, 2018), he told LVN 7, that the nursing staff was not changing his wound dressing during the night. The resident stated that he told one of his CNAs, and spoke with the Social Service Director (SSD) and Social Service Designee 1 (SSD 1) about his concern about 10 days ago (September 25, 2018), but things did not get better. When asked if he had told the SSD and SSD 1 how he felt, Resident 119 responded, "no" because the social service staff never asked him how he was feeling. The resident became tearful during the interview at times and wiped his tears stating that he felt neglected, sad, and wanted "to be out of here", meaning out of the facility. Resident 119 stated he did not know why the nurses were behaving like they did not care about the job and that he was having a hard time as a resident in the facility. Resident 119 stated that some staff were rough during care: one time, a staff member (tall male with curly hair) came into the room, did not even turn on the light, removed the sheet, kept turning him from side to side "rolling him like a burrito", and did not say "I am sorry." Resident 119 stated he did not ask that staff to change him anymore because "he treats people bad, is rough". On October 5, 2018 at 9:20 a.m., during an interview in the presence of the Administrator of the facility, the SSD stated she received Resident 119's grievance on September 10, 2018, and communicated the grievance to the QA Nurse. The SSD stated she returned to the resident and notified him that the QA Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 52 of 144 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 10/05/2018 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 would address his concern, but did not followup to ensure Resident 119's concerns were addressed. When presented with the Grievance Form completed on September 10, 2018, the Administrator stated that the investigation did not address the resident's concern and that no other interviews were conducted regarding the concerns. On October 5, 2018 at 11:11 a.m., during a Quality Assurance interview regarding Resident 119, in the presence of the QA Nurse, the Administrator, who was also the Abuse Prevention Coordinator, stated that the grievance was indicative of neglect (a type of abuse) and that he was not notified of the resident's concern. In addition, the QA Nurse stated that she did not notify the Abuse Prevention Coordinator of the resident's concerns. On October 5, 2018 at 4:11 p.m., during an interview, LVN 8 stated Resident 119 was carrying himself a bit more different (more understanding) when initially admitted, but now the resident was more lethargic, sad, weak, and on the "bluer side." LVN 8 stated that Resident 119 would usually request to have his wound dressing changed around 9 p.m. or 10 p.m. before going to sleep. LVN 8 stated she provided wound treatment when requested, but was unable to provide documented evidence she provided dressing changes to Resident 119's wound (right buttock and under scrotal area) in August 2018, and/or September 2018, during the 3 p.m. to 11 p.m. shift. On October 9, 2018 at 9:15 a.m., during a phone interview, the Wound Care Physician Consultant (WCMD) stated that Resident 119's wound had a lot of drainage. The WCMD stated that Resident 119's wound was not expected to get better and that the drainage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 53 of 144 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 10/05/2018 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 was not detrimental to the wound, but was more of a comfort concern because the drainage could be irritating to the surrounding skin. The WCMD stated that the physician order to provide wound care as needed meant that the nurses were to change the wound dressing whenever the dressing needed. There was no documented evidence in August 2018, and/or the September 2018, physician orders to indicate LVN 7, LVN 8, and or the QA Nurse notified the physician of Resident 19's request for wound dressing changes to be done during the evening shift (3 p.m. to 11 p.m. shift) in order to accommodate for the wound's drainage. A review of the facility's revised policy dated July 1, 2018, titled "Abuse Prohibition" indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. The facility will implement an abuse prohibition program through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occurrence 4. Identification of possible incidents or allegation which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and 7. Reporting of incidents, investigations, and center response to the results of their investigations. Neglect is defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 54 of 144 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 10/05/2018 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 Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Center Executive Director (CED) or designee will perform the following: 1. Enter allegation into the Risk Management System 2. Report allegations involving neglect, exploitation, or mistreatment (including injuries of unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury 3. Notify local law enforcement, Licensing Boards and Registries, and other agencies as required 4. Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported. 5. Initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated, causative factors, and intervention to prevent further injury. 6. The investigation will be thoroughly documented. Ensure that documentation of witnessed interviews is included. 7. The center will protect patients from further harm during an investigation 8. Assign a representative from Social Services or a designee to monitor the patient's feeling concerning the incident, as well as the patient involvement in the investigation. 9. The CED or designee will take all necessary corrective action depending on the result of the investigation. A review of the facility's revised policy and procedure dated March 1, 2018, titled, "Grievance/Concern," indicated all residents and/or representatives may voice grievances/concerns and recommendations for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 55 of 144 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 10/05/2018 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 changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. Social Service Personnel will serve as patient advocates in the grievance/concern process. When the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. For reports of abuse, follow the state-specific abuse policy for management of the incident and documentation requirements. The department manager will contact the person filling the grievance to acknowledge receipt, investigate the grievance, take corrective actions as needed, engage the support of the Ombudsman, if warranted, and notify the person filing the grievance of resolution within 72 hours by providing a copy of Grievance/Concern Form to the resident/resident representative. Review grievances/concerns at the Quality Improvement Committee meeting to identify trends. A review of the facility's revised policy dated March 1, 2018, titled "Person-Centered Care Plan" indicated a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary, in conjunction with the resident and/or resident representative, as appropriate, will establish the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 56 of 144 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 10/05/2018 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 factors related to the effectiveness of the plan of care. A review of the facility's Job Description for Director of Social Services 1 revised on August 9, 2012, indicated under the section of Advocacy, that the Director of Social Services 1: 1. Works with Social Service staff, interdisciplinary team, and administration to promote and protect resident rights and the psychological well-being of all patients/residents. Prevents and addresses patient/resident abuse as mandated by law and professional licensure. 2. Works with patients/residents, families, significant others and staff to provide support and information for taking a more proactive role in self-advocacy to improve the quality of life/care for individual patients/residents. 3. Respond to issues identifies by patients/residents and families to determine satisfaction with services. b. A review of the admission record indicated Resident 103 was admitted to the facility on August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral (low back area) region, and abnormal gait (the way one walks) and mobility. A review of the History and Physical report completed on August 6, 2018, indicated Resident 103 was awake and alert. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required extensive/total physical assistance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 57 of 144 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 10/05/2018 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 with bed mobility, transfer, toilet use, personal hygiene, and bathing. On October 2, 2018 at 12:45 p.m., during an observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated that he had requested to go to the restroom about an hour ago, but no one assisted him and he had soiled himself. During the same interview at 12:50 p.m., Resident 103 stated that a lot of facility staff did not stop to listen to his concerns or questions; some nursing staff would walk away when he would try to ask them a question. Resident 103 stated that about a couple of months ago around 5:30 a.m., a lady nurse (did not know the name) rough handled him during care, pulled his arm, was pushing him around really hard, and pushing him back and forth. Resident 103 stated that he did notify the head nurse (did not remember the head nurse's name). Resident 103 stated that there was another instance when one CNA was providing incontinence care, was pushing him hard and told him that he "was good for nothing". Resident 103 also stated that a couple of month ago, he requested a urinal from a CNA, and the CNA told him there was no more urinals and that he did not need it because he was using a "diaper". The resident stated that he notified the charge nurse. When asked how he felt about his concerns, resident stated that he felt sad and depressed. c. A review of the admission record indicated Resident 139 was admitted into the facility on September 5, 2018, with diagnoses that included high blood pressure, heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), and anemia (lower-than-normal number of red blood cells or hemoglobin in the blood). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 58 of 144 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 10/05/2018 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 History and Physical Report completed on August 8, 2018, indicated Resident 139 had the capacity to understand and make medical decisions. A review of Resident 139's Certificate of Terminal Illness dated September 5, 2018, indicated the resident was terminally ill and had a life expectancy of less than six months. Resident 139 was awake, alert, and oriented to person, place, and time. A review of the Minimum Data Set (a comprehensive assessment and care screening tool) dated September 12, 2018, indicated Resident 139 usually understood others and was usually able to make herself understood. The MDS also indicated Resident 139 required total assistance, one person physical assistance with toilet use and extensive assistance (two or more person assist) with bed mobility. On October 2, 2018 at 9:24 a.m., during an observation, Resident 139 was sitting in her wheelchair, awake, and oriented to person and place. During a concurrent interview, Resident 139 stated that the night shift nursing staff (females) were not nice and would rough handle her during the provision of incontinence care. The resident stated that she could not identify the involved female staff by names, because she could not read their identification badges. Resident 139 stated that the female nurse, who was assigned to her the night before was rough, "pushing and pulling her" (resident demonstrating as she was talking). Resident 139 also stated that the call light response during the night shift was 15 to 20 minutes and that sometimes, the nursing staff would not respond and address her needs (administration of pain medication), which did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 59 of 144 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 10/05/2018 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 not make her feel good.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 11/02/2018 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview the facility failed to ensure the Minimum Data Set (MDS- a comprehensive assessment and screening tool) under the dental/oral section was accurate and reflected the resident's actual condition for one of 50 sample residents (Resident 353). This deficient practice had the potential to result in delay of the provision of necessary dental/oral services. Findings: On October 4, 2018 at 9:32 a.m., Resident 353 was observed laying in bed and stated she has been asking to see a dentist since admission. The resident was observed with broken and missing teeth. A review of the admission record indicated Resident 353 was initially admitted on September 17, 2018, with diagnoses including hypertension (high blood pressure), and urinary tract infection (infection of any part of the urinary tract). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated September 24, 2018, indicated Resident 353's cognitive (mental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 60 of 144 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 10/05/2018 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 action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 353 required extensive assistance for moving in bed, transferring from bed to chair, dressing, toilet use and personal hygiene. The MDS indicated Resident 353 did not have any dental issues such as obvious or likely cavity or broken natural teeth. On October 4, 2018 at 2:33 p.m., during a concurrent record review and interview, Registered Nurse 4 (RN 4) confirmed the oral/dental assessment indicated Resident 353 had no dental problems. On October 4, 2018 at 2:50 p.m., during a concurrent observation and interview, RN 4 and RN 5 (the MDS nurses) assessed Resident 353 and confirmed the resident's dental status was not accurately reflected in the assessment. RN 5 agreed the MDS was not coded correctly because Resident 353 had broken and missing teeth.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 11/05/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 61 of 144 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 10/05/2018 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 (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: b. A review of the admission record indicated Resident 63 was admitted on April 27, 2018 with diagnoses including but not limited to hyperlipidemia (high cholesterol) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018, indicated Resident 63's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS indicated Resident 63 required extensive assistance for moving in bed, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 62 of 144 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 10/05/2018 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 transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of the "Recreation Comprehensive Assessment dated April 30, 2018, indicated it was somewhat important to Resident 63 to read the newspaper, listen to music, praying and meditating, attend religious activities. A review of Resident 63's "Risk for Limited Engagement" care plan created on May 4, 2018, indicated to invite and assist resident to activities and special events of interest and encourage family and friends' support an involvement in facility based activities. There was documented evidence of a care plan activity with specific interventions reflecting residents assessment and preferences. On October 4, 2018 at 8:19 a.m., during concurrent record review and interview, the Activity Director (AD) stated the care plan care should include the interventions the facility has in place for the residents. The AD stated the care plan should be based on the assessment and the interview with the resident's family. The AD stated Resident 63 care plan did not include all the interventions, and preferences of the resident. The AD stated the care plan does not indicate the intervention in place for the resident. On October 4, 2018 at 8: 32 a.m. during an interview, the Registered Nurse 4 (RN 4) agreed the care plan was not specific to the resident. A review of the facility policy and procedure titled "Person Centered Care Plan" revised on March 1, 2018, indicated the interdisciplinary team (a group of healthcare professionals) will establish the expected goal and outcomes of the care, the type, amount, frequency and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 63 of 144 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 10/05/2018 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 duration of care and any other factors related to effectiveness of the care plan; documentation will show evidence of patient's goals and preferences. The policy and procedure stated a comprehensive person-centered care plan must be developed and must describe services that are being provided. Based on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions for two of 50 sampled residents (Resident 119 and 63) by: 1. Failing to address Resident 119 's preferences and prevent a fall incident. 2. Failing to develop an individualized activity care plan with specific interventions for Resident 63, based on the residents activity assessment and preferences. These deficient practices placed Resident 119 at risk for injuries from a fall, and resulted in Resident 63 not being offered activities based of his preferences. Findings: a. A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable (the extent or progression of) due to coverage of wound bed by dead or non-viable (not expected to heal) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 64 of 144 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 10/05/2018 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 tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. The MDS also indicated Resident 119 had an ostomy (an artificial opening in an organ of the body) and did not have a history of falls. A review of the History and Physical (H&P) report completed on September 6, 2018, indicated that Resident 119 was alert and oriented. Resident 119 was admitted with diagnoses of metastatic colon cancer (spread of cancer cells from initial site of the disease to another part of the body). A review of the care plan initiated on September 10, 2018, indicated Resident 119 was at risk for falls due to functional mobility limitations, function independently, and noncompliance in using the call light. The goal indicated Resident 119 will have no falls with injury for 90 days. The care plan interventions included: place call light within reach while in bed or close proximity to the bed, remind resident to use call light when attempting to ambulate or transfer, monitor for and assist toileting needs, and assist resident getting out of bed with assist or staff using rolling walker. A review of the care plan initiated on September 10, 2018, indicated Resident 119 was incontinent of bowel and was unable to physically participate in a retraining program due to colostomy status. The care plan goal indicated Resident 119 will have incontinence care met by staff to maintain dignity and comfort and to prevent incontinence related FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 65 of 144 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 10/05/2018 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 complication. The care plan interventions included: apply moisture barrier to perianal and perineal area as indicated, assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, and use absorbent product as needed. The care plan did not address necessary care specific to Resident 119's colostomy care. On October 2, 2018 at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff was ignoring him (resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, wound dressing, colostomy bag timely, and did not empty his colostomy bag. Resident 119 stated that he was tired of asking the nursing staff to perform those tasks because it made him feel like a child. Resident 119 stated that he sometimes emptied his own colostomy bag every two days because some nursing staff did not want to empty it. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad." During the same interview at 11:33 p.m., Resident 119 stated that he fell about 45 minutes ago, pressed the call light button two or three times, but no one came. Resident 119 stated he was attempting to go to the restroom to remove his incontinence brief and empty his colostomy bag. Resident 119 stated he landed on his right buttock wound and heard a "pop" sound, then the wound started bleeding (the nurse had to apply deep pressure for about 10 minute). Resident 119 stated that he was weak and always pressed the call light before getting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 66 of 144 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 10/05/2018 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 up, so a staff could be with him. On October 2, 2018 at 12:19 p.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated that Resident 119 emptied his own colostomy bag because the resident knew how to care for his colostomy and preferred to care for it on his own. LVN 7 stated that Resident 119 had a fall incident earlier in the morning, when asked the resident what happened, Resident 119 responded that he was trying go to the restroom, pressed the call light three or four times, but no one responded. LVN 7 stated that Resident 119 had safety awareness, was able to call for assistance, and always called before attempting to get up. On October 4, 2018 at 10:37 a.m., during an observation, Resident 119 was lying in bed and LVN 6 was at the bedside administering medications. During a concurrent interview, Resident 119 stated that sometimes, he would change his colostomy bag and that when he asked some nurses to perform that task, they did not want to do it. Resident 119 stated that he did not receive any education/training from a facility staff on how to care for the colostomy. After Resident 119's statement, LVN 6, who was present during the interview, stated that it was the first time she was made aware that Resident 119 sometimes performed his own colostomy care. On October 4, 2018 at 11:12 a.m., during an interview, the Quality Assurance Nurse (QA Nurse) stated that Resident 119's fall risk assessment dated September 4, 2018, indicated a total score of five (resident was not at risk for fall). The QA nurse stated that the care plan for at risk for fall initiated on September 10, 2018, indicated Resident 119 was non-compliant in using the call light. However, the QA Nurse was unable to provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 67 of 144 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 10/05/2018 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 documented evidence the facility staff witnessed Resident 119 out of bed, without prior calling for assistance. On October 4, 2018 at 12:07 p.m., during an interview, LVN 7 stated that Resident 119 told him (about the second week after admission) that he changed his colostomy bag. LVN 7 stated that he did not notify anyone and did not document because he assumed the nurses knew, Resident 119 was changing his colostomy bag and performing colostomy care. LVN 7 reviewed Resident 119's care plan for bowel incontinence and stated the care plan did not address how to care for the resident's colostomy. A review of the facility's revised policy dated March 1, 2018, titled "Person-Centered Care Plan" indicated a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary, in conjunction with the resident and/or resident representative, as appropriate, will establish the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 11/02/2018 §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, mustFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 68 of 144 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 10/05/2018 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 (i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that the low air loss mattress (LAL- a device used in the prevention, treatment and management of pressure ulcers), pressure setting was maintained at pressure ordered by the physician for one of 50 sampled residents (Resident 65). This deficient practice had the potential to place Resident 65 at risk for developing new pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin), or worsening existing pressure sores. Findings: A review of the admission record indicated Resident 65 was readmitted to the facility on January 24, 2018, with diagnoses that included high blood pressure and contracture of muscle (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). A review of Resident 65's Braden Scale for Predicting Pressure Ulcer Risk (an assessment) form dated August 6, 2018, indicated a total score of 10. The risk assessment tool indicates a score of 10, signifies Resident 65 was at a high risk of developing a pressure ulcer. A review of Resident 65's physician order dated August 30, 2018, indicated to provide LAL mattress at a pressure of 150. A review of the care plan initiated on August 9, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 69 of 144 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 10/05/2018 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 2018, indicated Resident 65 had a re-opened pressure injury on coccyx area stated 2 (partial thickness loss of dermis) related to impaired sensation, history of pressure ulcer, incontinence, and limited mobility. The goal indicated that the wound will remain free from signs and symptoms of infection, the resident's wound will heal as evidenced by decrease in size, absence of erythema and drainage, and presence of granulation. The care plan intervention included: pressure redistribution surfaces to bed as per protocol, provide pericare/incontinence care as needed, and provide wound treatment as ordered. On October 2, 2018 at 8:40 a.m., during an observation in the presence of Certified Nursing Assistant 4 (CNA 4), Resident 65 was lying in bed and sleeping. The LAL mattress pressure setting was set at 50 pounds/soft. During a concurrent interview, CNA 4 stated that the machine was set at 50 pounds.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 11/02/2018 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide activites FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 70 of 144 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 10/05/2018 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 based on the residents preferences for one of 50 sample residents This deficient practice had the potential to negatively affect the residents mental wellbeing. Findings: A review of the admission record indicated Resident 63 was admitted on April 27, 2018 with diagnoses including but not limited to hyperlipidemia (high cholesterol) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018 indicated Resident 63's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS indicated Resident 63 required extensive assistance for moving in bed, transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of the "Recreation Comprehensive Assessment dated April 30, 2018 indicated it was somewhat important to Resident 63 to read the newspaper , listen to music , praying and meditating , attend religious activities . A review of Resident 63's activity log for the months of July, August and September 2018 indicated Resident resident reading the newspaper , listening to music visiting with family and looking out of the window. The activity log did not indicated attending religious activites, meditating , nor praying . On October 4, 2018 at 8:19 a.m. during an interview the Activity Director (AD) stated Resident 63 attends group activities . The AD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 71 of 144 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 10/05/2018 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 stated Resident 63 did not listen to music in his room and did only when he went to group activities . Resident did not have any equipment to his room to listen to music. On October 4, 2018 at 8:40 a.m. during an interview the Activities Assistant ( AA) stated Resident 63 was not taken to religious activities . AA stated Resident 63 used to get a newspaper in his native language but did not know what happened. A review of the facility policy and procedure titled " Treatment : Considerate and Respectful" revised on September 1, 2013 indicated the healthcare center will promote care for patients in a manner and in an environment that maintains and enhances each patient's dignity and respect in full recognition of his or her individuality . The policy and procedure further indicated the healthcare center will assist patients to attend activities of their own choosing .

F684 SS=E Quality of Care CFR(s): 483.25

F684 11/05/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 72 of 144 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 10/05/2018 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 Based on observation, interview, and record review, the licensed nursing staff failed to ensure residents received necessary care and services related to impaired skin integrity (right buttock wound) for one of 50 sampled residents (Resident 119) by failing to: 1. Accurately assess the location and type of Resident 119's wounds 2. Provide wound dressing change as requested by Resident 119 for 25 days (from September 10, 2018 to October 5, 2018), when the wound dressing was saturated with drainage. 3. Follow the recommendations of the Wound Care Physician Consultant (WCPC) to change Resident 119's wound dressing as needed. This deficient practices placed Resident 119 at risk for discomfort and infection, and resulted in Resident 119 feeling sad, neglected, and was subjected to mental anguish and distress as evidenced by crying, resident's verbalization of wanting to leave the facility due to unmet necessary wound care. Findings: A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status (an operation that creates an opening for the large intestine, through the abdomen), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 73 of 144 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 10/05/2018 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 stageable (extent or progression of) due to coverage of wound bed by dead or non-viable (not expected to heal) tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. The MDS indicated Resident 119 had an ostomy (an artificial opening in an organ of the body) and two unstageable pressure ulcer measuring 8 centimeters (cm) length by 5 cm width. A review of the History and Physical (H&P) report completed on September 6, 2018, indicated that Resident 119 was alert and oriented. Resident 119 was admitted with diagnoses of metastatic colon cancer (spread of cancer cells from initial site of the disease to another part of the body), metastatic locoregional right buttock and to lungs. The physical examination section indicated right buttock metastatic ulcer (indurated- a localized hardening of soft tissue of the body that becomes firm/hard). A review of Resident 119's care plan initiated on August 28, 2018, and revised on September 4, 2018, indicated the resident had altered skin breakdown related to recent surgery, limited mobility, right inferior pressure injury unstageable, right superior pressure injury unstageable, and under scrotal area pressure injury unstageable. The care plan goal indicated the wound will remain free from signs and symptoms of infection for 14 days and the resident wound will heal as evidenced by decrease in size, absence of erythema and drainage, and presence of granulation for 14 days. The care plan interventions included: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 74 of 144 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 10/05/2018 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 1. Apply barrier cream with each cleansing 2. Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to physician as indicated 3. Monitor for effectiveness and/or side effects of medication 4. Monitor for verbal and nonverbal signs of pain related to wound or wound treatment 5. Obtain dietitian consult as needed/ordered 6. Provide pericare/incontinence care as needed. A review of Resident 119's Skin Check dated August 28, 2018, September 4, 2018, and September 28, 2018, indicated the resident had left inferior (lower in place or position) and superior (a higher place or position) pressure ulcers. However, Resident 119's Wound Evaluation and Management Summary dated September 4, 11, 18, and 25, 2018 indicated the resident had a right superior buttock burn wound and a right inferior wound. A review of Resident 119's physician orders and the Treatment Administration Record did not indicate that the WCMD treatment plan was followed. The findings were as follow: 1. Right inferior buttock pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment (used to help the healing of burns and skin ulcers), cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 15, 2018 with end date of September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's right inferior pressure injury as ordered from September 15, 2018 to September 29, 2018. A review of Resident 119's Wound Evaluation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 75 of 144 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 10/05/2018 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 Management Summary dated September 18, 2018 and September 25, 2018, indicated the following right inferior's dressing treatment plan: Dry protective dressing once daily for 23 days, Alginate Calcium (a wound dressing used to manage exudates-pus and promote healing) once daily for 23 days, Santyl once daily for 30 days. 2. Right superior buttock pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 15, 2018 with end date of September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's right superior pressure injury as ordered from September 15, 2018 to September 29, 2018. A review of Resident 119's Wound Evaluation and Management Summary dated September 18, 2018, and September 25, 2018, indicated the following right superior's dressing treatment plan: Dry protective dressing once daily for 16 days, Alginate Calcium once daily for 16 days, Santyl once daily for 23 days. 3. Under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 15, 2018, with end date of September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's under scrotal pressure injury as ordered from September 15, 2018, to September 29, 2018. A review of Resident 119's Wound Evaluation and Management Summary dated September FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 76 of 144 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 10/05/2018 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 18, 2018, and September 25, 2018, indicated the following scrotum's dressing treatment plan: Dry protective dressing once daily for 23 days, Leptospermum Honey once daily for 30 days, Alginate Calcium once daily for 23 days, Santyl once daily for 30 days. 4. Right inferior buttock pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's right inferior pressure injury as ordered from September 29, 2018 to October 4, 2018. A review of Resident 119's Wound Evaluation and Management Summary dated October 2, 2018, did not indicate a right inferior's dressing treatment plan (Right inferior buttock resolved) 5. Right right superior buttock pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's right superior pressure injury as ordered from September 29, 2018 to October 4, 2018. A review of Resident 119's Wound Evaluation and Management Summary dated October 2, 2018, indicated the following right superior's dressing treatment plan: Dry protective dressing once daily for 30 days, Alginate Calcium once daily for 30 days, Santyl once daily for 9 days. The WCMD recommended nutrition consultation and pre-albumin 3. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 77 of 144 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 10/05/2018 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 6. Under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated September 29, 2018. The TAR indicated the nursing staff provided treatment to Resident 119's under scrotal pressure injury as ordered from September 29, 2018 to October 4, 2018. A review of Resident 119's Wound Evaluation and Management Summary dated October 2, 2018, indicated the following scrotum's dressing treatment plan: Dry protective dressing once daily for 9 days, Alginate Calcium once daily for 9 days, Santyl once daily for 9 days, and discontinue Leptospermum Honey (used to treat pressure ulcers and other wounds). A review of the Grievance/Concern Form indicated Resident 119 filed a grievance on September 10, 2018, indicating that his wound dressing was not being changed during the second (3 p.m. to 11 p.m.) and third (11 p.m. to 7 a.m.) shifts. The investigation section indicated that the charge nurse was interviewed and that the charge nurse stated Resident 119's dressing was changed. The Resolution of Grievance/Concern section indicated that Resident 119 was informed that the charge nurse changed the dressing and that according to the charge nurse, the resident forgot. A review of the Resident 119's Treatment Administration Record (TAR) from August 28, 2018 to October 5, 2018, did not indicate that the nursing staff provided wound care/dressing change on an as needed basis. On October 2, 2018 at 11:31 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 78 of 144 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 10/05/2018 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 observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff was ignoring him (resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his wound dressing timely. Resident 119 stated that the nursing staff (assigned after 3 p.m.) did not want to change his wound dressing and that he notified (on an unspecified date) the social worker and the "social worker helper," who stated they will look into it and take care of the concern. Resident 119 stated that he notified Licensed Vocational Nurse 7 (LVN 7), who told the resident to "insist" that the nursing staff assigned after 3 p.m. change his wound dressing in the evening. Resident 119 stated that sometimes, the wound dressing would be saturated with drainage and that he would remove the "cushion- spongy part of the dressing" and change the incontinence brief (soiled by drainage). Resident 119 stated that when the wound dressing would become saturated with drainage, the drainage would go on the surrounding skin and irritate the skin; the resident would have to get a small towel and wipe the skin frequently until the morning shift. Even the incontinence brief would be wet. Resident 119 stated that LVN 8 was one of the nurses that did not want to change his wound dressing. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad." On October 2, 2018 at 12:19 p.m., during an interview, LVN 7 stated that Resident 119 reported to him twice, the first or 2 week of the resident's admission (last week of August 2018 or first week of September 2018), that his wound dressing was saturated with drainage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 79 of 144 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 10/05/2018 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 that the nurses during the evening/night shifts did not change his the dressing. LVN 7 stated that he notified the charge nurse (could not remember the name of the charge nurse) of Resident 119's complaint when the resident reported the concerns. LVN 7 stated that prior to changing Resident 119's wound dressing in the morning, the wound dressing would be saturated with drainage, which would lead the incontinence brief to be soiled as well. On October 2, 2018 at 2:55 p.m., during an interview, the Social Service Director (SSD) stated that the facility's procedure was to complete a grievance form whenever a resident filed a grievance (verbal or written). The grievance form would be given to the Social Service Department, which would assign the grievance to the appropriate discipline for resolution. On October 3, 2018 at 7:15 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated that last week (could not remember the specific date), Resident 119 verbalized to her that the nursing staff did not change his wound dressing in the afternoon. CNA 2 stated that she notified LVN 6, who went to the resident's room and changed the resident's wound dressing. CNA 2 stated that Resident 119 had not verbalized he was depressed or sad, but CNA 2 could tell on the resident's face that he sad (could not give specific details). On October 3, 2018 at 8:17 a.m., during an interview, LVN 6 stated that Resident 119 reported to her that his wound dressing was not being changed, which prompted LVN 6 to complete the grievance form on September 10, 2018. LVN 6 stated that Resident 119's wound had a lot of drainage. On October 3, 2018 at 9:24 a.m., during an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 80 of 144 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 10/05/2018 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 interview, the Quality Assurance Nurse (QA Nurse) stated she was unable to provide documented evidence the licensed nursing staff provided wound care/ wound dressing change to Resident 119's wound areas (right inferior and superior buttock, under scrotal area) in August 2018, and September 2018, during the 3 p.m. to 11 p.m. and/or 11 p.m. to 7 a.m. shift. On October 5, 2018 at 8:45 a.m., during wound care observation, LVN 7 removed the right buttock dressing, which was saturated with serous sanguineous (containing both blood and the liquid part of blood) drainage. The wound was hard and there was a strong, foul odor coming from the wound. The periwound was macerated (occurs when skin is in contact with moisture for too long, often associated with improper wound care) with a grayish color and the wound had yellowish and granulated (healthy) tissues. LVN 7 measured the right buttock wound and stated that the dimensions were 12 cm length by 12 cm width. LVN 7 cleansed the wound with a cleansing solution (spray), patted dry, applied Santyl, and covered the wound with dry dressing. LVN 7 performed the same wound care treatment to Resident 119's under scrotal wound area. LVN 7 did not apply Alginate Calcium to Resident 119's right buttock and scrotal wounds. On October 5, 2018 at 1:31 p.m., during an interview, LVN 7 stated that he made round with the WCMD on October 2, 2018 and the physician gave him a verbal order to apply Santyl to Resident's right buttock wound. LVN 7 stated he reviewed the WCMD's notes dated October 2, 2018, but missed Alginate Calcium on the dressing treatment plan. LVN 7 stated that he did not apply Alginate Calcium to Resident 119's right buttock and scrotal wound earlier during wound care treatment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 81 of 144 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 10/05/2018 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 observation. On October 5, 2018 at 3:49 p.m., during an interview, Registered Nurse 3 (RN 3) stated that the WCMD's dressing treatment plans and recommendation for nutritional consultation and pre-albumin 3, was not followed through. RN 3 stated the treatment nurses were responsible for following up with the recommendation of WCMD. On October 9, 2018 at 9:15 a.m., during a phone interview, the WCMD stated that Resident 119's wound had a lot of drainage. The WCMD stated that Resident 119's wounds were not expected to get better and that the drainage was not detrimental to the wound, but was more of a comfort concern because the drainage could be irritating to the surrounding skin. The WCMD stated that the physician order to provide wound care as needed meant that the nurses were to change the wound dressing whenever dressing needed. The WCMD stated that it was his practice to make rounds with the treatment nurse when examining the residents, his recommendations would be verbally communicated during rounds, and he would document his recommendations as well. A review of the facility's revised policy dated November 28, 2016 and titled "Skin Integrity Management" indicated that the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patient's for changes and implement revisions to the plan of care as needed. Review pre-admission information to plan for patient's needs prior to admission. Complete comprehensive evaluation of the patient upon admission/re-admission to the facility. Identify patient's skin integrity status FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 82 of 144 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 10/05/2018 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 need for prevention intervention or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission/re-admission and weekly. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Implement special wound care treatments/techniques, as indicated and ordered, Notify Dietitian and/or rehabilitation services as indicated, Notify patient, family, health care decision maker of plan of care, Review care plan weekly and revised as indicated.

F689 SS=E Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/05/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: d. On September 2, 2018 at 8:36 a.m. Resident 63 was observed sitting in wheelchair near bed, one landing pad on the side the bed closest to the door, no landing pad on the other side of the bed closer to the wall A review of the admission record indicated Resident 63 was admitted on April 27, 2018, with diagnoses including but not limited to hyperlipidemia (high cholesterol) and major depressive disorder. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 83 of 144 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 10/05/2018 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 Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018, indicated Resident 63's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS indicated Resident 63 required extensive assistance for moving in bed, transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of Resident 63's care plan initiated on April 27, 2018, indicated the resident was at risk for falls and injury and the interventions included assisting the resident getting in and out of bed (with extensive assistance), assist resident with ambulation providing extensive assistance. New interventions were added on May 7, 2018. A review of progress notes dated May 8, 2018 indicated Resident 63 had a fall on May 7, 2018, and an IDT post fall was held on May 8, 2018. New interventions were added to the care plan on May 7, 2018. A review of the SBAR Communication Form (Situation, Background, Assessment and Recommendation - a communication tool) dated May 13, 2018, indicated the resident fell. No new interventions were added to the care plan. A review of the "Change of Condition Evaluation" dated August 22, 2018, indicated Resident 63 had a witnessed fall. No new interventions were added to the care plan. A review of the "Change of Condition Evaluation" date October 3, 2018, indicated Resident 63 sustained another fall. On October 4, 2018 at 8:52 a.m., during a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 84 of 144 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 10/05/2018 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 concurrent record review and interview, Registered Nurse 4 (RN 4) stated Resident 63 was found sitting on the floor the night before near the foot of the bed. RN 4 stated Resident 63 should have two floor mats on the floor instead of just one of one side of the bed. On October 4, 2018 at 11:46 a.m., during a concurrent record review and interview, RN 4 stated could not find any new interventions added to the care plan after each fall. RN 4 stated the care plan should be updated after each fall. RN 4 stated she could not find any documented evidence of a post fall IDT meeting after Resident 63 fell on May 13, 2018 and August 22, 2018. On October 5, 2018 at 4:08 p.m., during an interview both RN 4 and RN 5 confirmed they could not find and the post fall IDT meeting notes for Resident 63 who fell on May 13, 2018, on August 22, 2018, and on October 3, 2018. e. On October 2, 2018 at 11:44 a.m., during a tour of the facility, Resident 352's family member stated the resident had fallen in the facility 4 times. Resident 352 was noted with an ice pack on his left hand. The resident was awake and alert and stated he had a headache. Resident 352 had a landing mat on the side of the bed closest to the door but no landing pad on the other side. On October 4, 2018 at 8:56 a.m., Resident 352 was observed laying in bed, there one landing mat on the side of the bed closest to the door. A review of the admission record indicated Resident 352 was admitted on September 13, 2018, with diagnoses including but not limited to alcohol dependence, and rhabdomyolysis (muscle injury that results from the death of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 85 of 144 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 10/05/2018 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 muscle fibers and release of their contents into the bloodstream). This can lead to serious complications such as kidney failure. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018, indicated Resident 352's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS indicated Resident 352 required extensive assistance for moving in bed, transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of the care plan initiated on September 13, 2018, indicated Resident 252 was at risk for falls and the only intervention was placing all necessary personal items within reach. A review of Resident 352's "Witness Interview Record" dated September 13, 2018, indicated the resident fell, landing on his left side. There no documented evidence indicating the care plan was revised and updated after this fall. A review of Resident 352's "Witness Interview Record" dated September 14, 2018, indicated the resident had a second fall and was found on the floor in a sitting position. The resident was interviewed and he stated his leg was caught on the blanket causing him to fall. There was no documented evidence indicating the care plan was revised and updated after this fall. A review of Resident 352 fall interview record dated September 20, 2018, indicated a staff member saw the resident standing up to go to the bedside commode, fell and landed on the floor mat. There was no documented evidence of Resident 352, being interviewed regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 86 of 144 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 10/05/2018 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 the fall. A review of the care plan indicated it was not revised and updated until September 27, 2018, a week after Resident 352's third fall, on September 20, 2018. On October 5, 2018 at 8:13 a.m., during a concurrent record review and interview, RN 4 stated there was no documentation indicating, Resident 352 was interviewed regarding the fall. RN 4 stated the resident should been interviewed during the fall investigation. RN 4 stated there was no changes to the care plan after each fall. On October 5, 2018 at 3:19 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 352 should have two landing Mats in the room since he can fall on either side of the bed. LVN 1 stated the landing Mats should have been added to the care plan. On October 5, 2018 at 3:42 during an interview RN 4 stated the fall management for the facility included creating an incident report, notifying the resident's physician and responsible party, conducting an investigation by interview the staff, the resident, the resident's roommate, monitoring the resident for 72 hours. RN 4 stated the facility did not do post fall assessments and that has not been the practice. On October 5, 2018, at 3:51 p.m., during a concurrent record review and interview RN 6 stated the facility usually conducts an IDT meeting after a fall. RN 6 stated he could not find any documented evidence of post fall IDT for Resident 352. A review of the facility policy and procedure titled "Fall Management" revised on March 15, 2016, indicated patients experiencing a fall will receive appropriate care and investigation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 87 of 144 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 10/05/2018 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 the cause. The policy and procedure indicated if a patient falls document the investigations, update the care plan to reflect new interventions, conduct interdisciplinary team meeting within 72 hours of a fall and the center executive director and the center nurse executive will conduct a post fall review. b. A review of Resident 96's admission record, dated 10/5/18 and timed 1:42 p.m., indicated the resident, whose primary language was the not the dominant language spoken by the facility staff. Resident 96 was admitted on 2/7/18, and his diagnoses included respiratory failure, congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles), and difficulty in walking. A review of Resident 96's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 8/14/18, indicated the resident had adequate hearing, adequate vision with glasses, and had clear speech. Resident 96 was able to express ideas and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 88 of 144 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 10/05/2018 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 wants, to understand verbal content with clear comprehension, and no cognitive impairment. A review of Resident 96's physician's order dated 2/8/2018, indicated an order for Plavix (a medication used to prevent heart attack, stroke, or other vascular events in people who are at high risk) 75 milligrams (mg) by mouth daily for blood thinner. During an observation on 10/4/18 at 1:00 p.m., Resident 96 was observed in his wheelchair in the hallway near Room 53. The resident was holding his left hand in the air with blood dripping from his first and second finger. The resident stated in his primary language, "My finger is bleeding. I cut it on the door" and indicated the door to the courtyard, where he had been sitting. "I was pulling myself through the doorway, and I cut my left hand." Upon closer inspection of the door, there was a sharp pointed, metal shard observed sticking out of the doorway casing about 2.5 feet from the floor. LVN 3 notified the Maintenance Director (MD) and MD came immediately to remove the shard. During an interview with Resident 96 and Licensed Vocational Nurse (LVN 3) on 10/4/18 at 1:15 p.m., LVN 3 stated she applied pressure to Resident 96's fingers and the bleeding stopped right away. LVN 3 stated she cleansed the resident's wound and placed a bandage. Resident 96 stated, "It doesn't hurt much." During an interview on 10/5/18 at approximately 4:00 p.m., the MD stated no one had reported the shard to him before 10/4/18. A review of the facility policy and procedure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 89 of 144 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 10/05/2018 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 titled "OPS200 Accommodation of Needs" dated 11/28/17, indicated the facility must provide: "1.1 A safe, clean, comfortable, and homelike environment, allowing the resident to use his/her personal belongings to the extent possible." "1.1.1 This includes ensuring that the resident can receive care and services safely and that the physical layout of the Center maximizes resident independence and does not pose a safety risk." c. A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable-the extent or progression of, due to coverage of wound bed by dead or non-viable, not expected to heal, tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. The MDS indicated Resident 119 had an ostomy (an artificial opening in an organ of the body). A review of the History and Physical (H&P) report completed on September 6, 2018, indicated that Resident 119 was alert and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 90 of 144 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 10/05/2018 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 oriented. Resident 119 was admitted with diagnoses of metastatic colon cancer (spread of cancer cells from initial site of the disease to another part of the body). A review of the care plan initiated on September 10, 2018, indicated Resident 119 was incontinent of bowel and was unable to physically participate in a retraining program due to colostomy status. The care plan goal indicated Resident 119 will have incontinence care met by staff to maintain dignity and comfort and to prevent incontinence related complication. The care plan interventions included: apply moisture barrier to perianal (around the anus) and perineal (between the anus and the external genitalia) area as indicated, assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, and use absorbent product as needed. The care plan did not address necessary care specific to Resident 119's colostomy care. A review of the physician orders dated August 28, 2018, indicated to provide Resident 119 with the following colostomy services: 1. Colostomy appliance change as needed; 2. Colostomy appliance change every three days; 3. Colostomy care as needed; and 4. Colostomy care every shift A review of the Resident 119's Treatment Administration Record (TAR) from September 1, 2018 to October 4, 2018, did not indicate that the nursing staff provided colostomy care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 91 of 144 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 10/05/2018 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 on an as needed basis. The TAR did not indicate the licensed nurses provided colostomy care on September 1, 4, 16, 20, 21, and 22, 2018 during the 3 p.m. to 11 p.m. shift. On October 2, 2018 at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff was ignoring him (resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, colostomy bag timely, and did not empty his colostomy bag. Resident 119 stated that he was tired of asking the nursing staff to perform those tasks, because it made him feel like a child. Resident 119 stated that he sometimes emptied his own colostomy bag every two days, because some nursing staff did not want to empty it. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad." During the same interview at 11:33 p.m., Resident 119 stated that he fell about 45 minutes ago, pressed the call light button two or three times, but no one came. Resident 119 stated he was attempting to go to the restroom to remove his incontinence brief and empty his colostomy bag. Resident 119 stated he landed on his right buttock wound and he heard a "pop" sound, then the wound started bleeding (the nurse had to apply deep pressure for about 10 minute). On October 2, 2018 at 12:19 p.m., during an interview, LVN 7 stated that Resident 119 emptied his own colostomy bag, because the resident knew how to care for his colostomy and preferred to care for it on his own. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 92 of 144 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 10/05/2018 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 On October 4, 2018 at 10:37 a.m., during an observation, Resident 119 was lying in bed and LVN 6 was at the bedside administering medications. During a concurrent interview, Resident 119 stated that sometimes, he would change his colostomy bag and that when he asked some nurses to perform that task, they did not want to do it. Resident 119 stated that he did not receive any education/training from a facility staff on how to care for the colostomy. After Resident 119's statement, LVN 6, who was present during the interview, stated that it was the first time she was made aware that Resident 119 sometimes performed his own colostomy care. On October 4, 2018 at 12:07 p.m., during an interview, LVN 7 stated that Resident 119 told him (about the second week after admission) that he changed his colostomy bag. LVN 7 stated that he did not notify anyone, and did not document because he assumed the nurses knew, Resident 119 was changing his colostomy bag and performing colostomy care. LVN 7 reviewed Resident 119's care plan for bowel incontinence and stated that the care plan did not address how to care for the resident's colostomy. On October 5, 2018 at 8:45 a.m., during an observation, Resident 119's colostomy bag was full and was leaking. On October 5, 2018 at 9 a.m., during an interview in the presence of the Administrator of the facility, Resident 119 stated that LVN 10 did not want to empty and/or change his colostomy bag yesterday (October 4, 2018). Resident 119 stated that he would change and/or empty his colostomy bag because some people did not want to do it. During the interview, Resident would become tearful at times and wipe his tears stating that he felt FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 93 of 144 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 10/05/2018 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 neglected, sad, and wanted "to be out of here", meaning out of the facility. Resident 119 stated that he did not know why the nurses were behaving like they did not care about the job, and that he was having a hard time as a resident in the facility. A review of the facility's revised policy dated March 1, 2018, titled "Person-Centered Care Plan" indicated a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary, in conjunction with the resident and/or resident representative, as appropriate, will establish the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and/or failed to ensure a resident received adequate supervision to prevent a fall for five of 50 sampled residents(Resident 47, 96, 119, 63 and 352 by: 1. Failing to assess 47 being at high risk for falls requiring interventions to prevent further falls and injury. 2. Failing to ensure there were no sharp edges on the patio doorway casing for Resident 96. 3. Failed to provide assistance to the bathroom and assistance with colostomy care when requested by Resident 119. 4. Failed to develop person-centered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 94 of 144 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 10/05/2018 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 interventions indicating how and when to care for Resident 119's colostomy. 5. Failing to update Resident 63's fall interventions after each fall as indicated in the facility policy. 6. Failing to conduct a post fall IDT (interdisciplinary team) meeting for Resident 63 after each fall as indicated in the facility policy. 7. Ensure the residents had two landing mats in the room rather than just one to minimize injuries in an event of a fall. 8. Conduct a thorough investigation when Resident 352 fell on September 20, 2018. These deficient practices had the potential to result in avoidable injuries for Resident 47, 63, and 352, resulted in Resident 96 cutting his left finger when propelling himself through the doorway, and resulted in Resident 119 sustaining a fall while attempting to go to the restroom to empty his colostomy (an operation that creates an opening for the large intestine, through the abdomen) bag without assistance. Findings: a. A review of Resident 47's Admission Record indicated she was originally admitted to the facility on July 16, 2018, with diagnoses that included, muscle weakness (generalized), muscle wasting and atrophy (decreased muscle strength), depression (a chronic mood disorder, associated with sadness), chronic pain syndrome, status post cardiovascular FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 95 of 144 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 10/05/2018 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 accident (CVA, or cerebral infarction (a stoke) from a lack of blood flow to the brain) with right hemiplegia (affecting one side of the body) and hemiparesis (weakness on half of the body since August 2014). On August 17, 2018 at 6:16 p.m., and transferred to the GACH ER (General Acute Hospital/Emergency Room), and transferred back to the facility, approximately 5.5 hours later, at 11:40 p.m., due to a mechanical fall from the bed. A review of Resident 47's Fall Risk Assessment dated July 16, 2018, indicated a fall risk score of 11 (a score of 12 and higher indicates high risk for falls). According to the facility's Pharmacy's Drug Regimen Review (DRR), dated September 6, 2018, indicated Resident 47 had experienced a recent fall. Recommendations included to evaluate medication (s) contributing to falls and minimize or discontinue any of these therapies if possible in order to minimize the risk of fall due to adverse drug effects. If this therapy is continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual, and b) the facility interdisciplinary team (IDT) ensure ongoing monitoring for effectiveness and potential adverse consequences. A review of Resident 47's Admission Minimum Data Set (MDS - an assessment and care screening tool), dated July 23, 2018, indicated the Resident 47 understood staff during interviews, required extensive assistance with two-person physical assist during bed mobility (how resident moves to and from lying position, turns side to side) and transfers (how resident moves between surfaces). According to Resident 47's, CAA (Care Area Assessment), Resident 47 was triggered for falls. Under FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 96 of 144 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 10/05/2018 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 section referral to other disciplines, is a referral to another discipline warranted and physical therapy (PT) to provide therapeutic exercise/activities to minimize decline. and how to prevent injuries in the event of a fall. A review of Resident 47's Initial Admission Nursing Assessment, dated July 16, 2018, at 7:35 p.m. indicated the resident had a stroke with right sided weakness, requiring rehabilitation. The resident was assessed being bedfast, confined to bed, with the potential to slide down in chair and bed. A review of Resident 47's plan of care, dated July 28, 2018, titled resident at risk for falls, bed confined and history of CVA with weakness, indicated interventions to remind the resident to use the call light when attempting to transfer, placing all of resident's necessary personal items within reach, monitor for and assist the resident with toileting needs and provide frequent visual checks. There was no interventions indicating alternative measures to prevent falls such as physical therapy or therapeutic exercises/activities to minimize decline preventing further falls. A review of the facility's Situation, Background, Appearance and Review (SBAR) and Fall Report of Incident, dated August 17, 2018, indicated Resident 47 had an unwitnessed fall at 4:30 p.m. from LAL (low air loss) mattress, laceration to left lateral head noted. The resident's vital signs were taken (body temperature, pulse and respiration rate, and blood pressure). 9-1-1 paramedics were called and the resident's physician was notified at 6:25 p.m. (2 hours after the incident). A review of the facility's RMS (Resident Management System) Event Summary Report FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 97 of 144 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 10/05/2018 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 dated, August 17, 2018 at 4:30 p.m., indicated at 4:30 p.m., Resident 47 had an unwitnessed fall from his lower air loss (LAL) bed. The nurse found Resident 47 lying on the floor on the left lateral side, with both of legs still in the bed. Resident 47 was noted to have a small laceration (a deep cut or tear in skin or flesh). A gauze was applied to the resident's head. The Report further indicated Resident 47 stated that he sneezed five times and fell. 9-1-1 was called and Resident 47 was transported to the GACH. A review of the Resident 47's GACH ER Triage Report, dated August 17, 2018, at 5:21 p.m., indicated, the resident fell, sustaining an abrasion to the left parietal (scalp area). Resident 47's pain level was a 5 out of 10 (10 being highest pain) on the numeric pain scale location head, vital signs 159/89 mmHg blood pressure, temperature 97.9* Fahrenheit, 89 pulse rate, 20 respiratory rate. A review of Resident 47's updated care plan for resident at risk for falls and having a history of CVA (stroke) with weakness that was created on August 21, 2018, indicated interventions to apply floor mats on each side of the residents bed. On October 3, 2018, at 7:27 a.m., during a medication pass observation with Licensed Vocation Nurse 8 (LVN 8), Resident 47 was observed in bed. There were no floor landing mats on the floor. During a subsequent bedside observation and interview, on October 4, 2018, at 8:27 a.m., LVN 8 stated the certified nursing assistant (CNA), can get Resident 47, "A new" landing mat from housekeeping. A landing mat still had not been replaced during this time. On October 3, 2018, at 8:51 a.m., during an interview, LVN 14, stated Resident 47 had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 98 of 144 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 10/05/2018 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 fallen off from the bed, approximately three months ago. On October 3, 2018, at 8:52 a.m., during an interview, Resident 47 stated, "I never had one", (referring to bedside landing floor mats). During a subsequent interview, on October 4, 2018 at 11:33 a.m. Resident 47 was observed having a sensory touch pad call light next to his left cheek, Resident 47 stated on the date of the fall incident on August 17, 2018 the resident recalled sneezing five times and slid off the left side of the bed. A review of Resident 47's GACH ED History and Physical, dated August 17, 2018 at 5:30 p.m., indicated Resident 47 had a fall, with left scalp abrasion. Under History of Present Illness: Resident 47 presented to the ED for an abrasion to his left parietal region status post fall at nursing facility. Upon physical exam: Resident 47 had an abrasion to his left parietal scalp, without a laceration or hematoma. The resident stated that he accidentally fell out of bed around 3 p.m. today. Since then he had a non-radiating, constant, moderate headache. The Resident was awake and alert. Upon further assessment, Resident 47 vomited. Under ED Decision making: Resident had a history of hypertension (high blood pressure) and CVA chronic right lower extremity weakness present to the emergency department after a mechanical fall out of the bed earlier today. Resident 47's CT (X-ray scan) imaging was ordered, with unremarkable results. A review of a physician's order dated August 20, 2018, indicated Resident 47 had a physician's order for bilateral 1/4 th inch side rails. A review of the facility's, Consent For Use Of Bed Rails, dated August 20, 2018, indicated Resident 47 consented, for the use, benefits, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 99 of 144 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 10/05/2018 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 risk of bedrails, via of his signature, for the use of bedrails. However, this was one day after Resident 47 fell on August 17, 2018. A review of Resident 47's Physician's order dated, August 21, 2018 at 12:54 p.m., indicated to monitor left frontal area laceration with steristrips, for any signs or symptoms of infection every day and report to the physician promptly if there is any. Every day shift and one time only for first day. A review of the facility's Change in Condition follow up licensed nurses note, dated August August 18, 2018, at 12:30 a.m., indicated this is a follow-up note from the accident/incident/fall in past 72 hours at occurred on August 17, 2018, provided floor mats on the side. However, this intervention was after Resident 47 fell. . A record review of the facility's undated, Summary of investigation: Root Cause/Conclusion; indicated due to Resident 47's involuntary movements during sneezing and repositioning on one due to his wound to his coccyx, Resident 47 slid off his LAL mattress. The fall was unavoidable due to Resident 47's uncontrollable spasms while sneezing. RN 9, indicated that Resident 47 did not use his call light, because he was not trying to get up, he was sneezing. However, RN 9, stated the facility did obtain a physician's order for bilateral floor landing mats for Resident 47. On October 3, 2018, at 2:37 p.m., during an interview, the DON, stated Resident 47's did not have bilateral floor mats on August 17, 2018, when he fell, because the nursing staff did not care plan, and did not have physician's order, for bilateral floor mats, until August 21, 2018.. However, this was four days after Resident 47 sustained a painful head injury in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 100 of 144 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 10/05/2018 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 facility, before he was transferred to the GACH ER to rule out a cerebral bleed via CT Scan, on August 17, 2018. On October 4, 2018, 10:21 a.m., during and interview and record review, with the facility's Quality Assurance Registered Nurse, (RN 5), stated the facility did not care plan bilateral floor landing mats until August 21, 2018, 36 days after Resident 47's initial admission, and 32 days after Resident 47's mechanical fall from his bed to the floor, on August 17, 2018, at 4:30 p.m. On October 4, 2018, at 4 p.m., during a subsequent bedside observation, Resident 47's bed was observed was observed waist level to LVN 13. During an interview, LVN 13 indicated, the bed was not lower, because "I don't put urinary (Foley) catheters on the floor," while she lowered Resident 47's bed. However, the facility did not follow Resident 47, July 28, 2018's care plan, titled Resident is at risk for falls:Bed confined due to his history of CVA with weakness. The care plan's with nursing interventions, included frequent visual checks and a low bed. However, this did not happen. A review of the facility's policy and procedure titled, "Falls care Delivery Process," dated, July 25, 2016, indicated fall risk is an interprofessional process. This means that the most successful fall program is a collaboration of all disciplines to identify and manage risk factors and causes. The policy and procedure section "Universal" indicates fall prevention measures should be standardized within 24 hours of the admission process, regardless to risk or fall history. A review of the facility's Fall Management policy and procedure, dated March 15, 2016, indicated patients will be assessed for falls risk FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 101 of 144 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 10/05/2018 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 as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. However, this did not happen. A review of the facility's policy and procedure, dated March 1, 2018, indicated the facility must develop and implement a baseline personcentered care plan within 48 hours for each patient that includes the instructions needs to provide effective and person-centered care that meet professional standards of quality care. Documentation will show evidence of: -Patient's goals and preferences; -Patient status in triggered Care Area Assessments (CAAs); -Development of care planning interventions for all CAA triggered by the MDS Nurse; and rationale for not care planning for a specific triggered CAA. -The care plan will be reviewed and revised by the interdisciplinary team after each assessment. Under Person-Centered Care: A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments.

F690 SS=E Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 11/05/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 102 of 144 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 10/05/2018 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 §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: b. On October 2, 2018 at 9:04 a.m., during a tour of the facility Resident 53 stated she had been waiting for 30 minutes to have her diaper changed. Resident stated she has a wound on her back. Resident 53 stated she urinates often because she takes Lasix (a mediation used to reduce extra fluid in the body and causes a person to urinate often) and sitting on wet diaper made her feel "pretty bad". A review of the admission record indicated Resident 53 was admitted on October 17, 2017, with diagnoses including but not limited FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 103 of 144 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 10/05/2018 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 to hypertension (high blood pressure), and pressure ulcer of sacral region (skin injurybedsore, located on the lower back at the bottom the spine). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated July 24, 2018, indicated Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 53 required extensive assistance for dressing, toilet use and personal hygiene. A review of Resident 53's physician order dated April 19, 2018, indicated to give the resident Lasix 20 milligram (mg) one time a day. A review of Resident 53's Nursing Assessment dated July 24, 2018, indicated the resident was occasionally incontinent of bowel and bladder but it did not indicate what kind of urinary incontinence. The assessment indicated a trial of toileting program was not attempted. On October 5, 2018 at 1:32 p.m., during an interview, Registered Nurse 2 (RN 2) stated Resident 53 did not have a voiding (urinating) daily and was not on a toileting program. RN 2 stated assessment, voiding diaries were not being done in the past, and the facility has now started doing it for the new admission. c. A review of the admission record indicated Resident 63 was admitted on April 27, 2018, with diagnoses including but not limited to hyperlipidemia (high cholesterol) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated May 4, 2018, indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 104 of 144 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 10/05/2018 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 63's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired. The MDS indicated Resident 63 required extensive assistance for moving in bed, transferring from bed to chair, dressing, eating, toilet use and personal hygiene. A review of the Nursing Assessment dated May 4, 2018, indicated Resident 63 was frequently incontinent of bowel and bladder. The assessment did not indicate the kind of bladder incontinence Resident 53 had. The assessment indicated no trial of a toileting program was attempted. On October 4, 2018 at 11:54 a.m., during a concurrent record review and interview, Registered Nurse 4 (RN 4) stated could not find any documentation regarding a bowel and bladder program for Resident 53. A review of the facility policy and procedure titled "Continence Management" revised on March 1, 2018, indicated a urinary incontinence assessment and/or bowel incontinence assessment and the three-day continence management diary will be completed if the patient is incontinent upon admission or readmission and with a significant change as part of the nursing assessment . The policy and procedure further indicate if a patient is incontinent initiate a three day continence management diary and develop a care plan based on information from assessment and diary. Based on observation, interview, and record review, the nursing staff members failed to ensure that three of 50 sampled residents (Resident 103, 53, 63), were provided bowel and bladder training and a toileting program to restore as much bladder function as possible by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 105 of 144 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 10/05/2018 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 1. Failing to ensure Resident 103, who was assessed as always incontinent of urine and bowel was provided bowel and bladder training and/or a toileting program. 2. Failing to ensure a bowel and bladder assessment was completed for Resident 53 and Resident 63, in order to determine if the residents may benefit from a bladder and or bowel training program. These deficient practices resulted in continued urinary incontinence for Resident 103, 53 and 63, and can negatively affect the residents' psychosocial well-being, and had the potential to place Resident 103 at risk for urinary tract infection. Findings: a. A review of the admission record indicated Resident 103 was admitted to the facility on August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region, and abnormal gait and mobility. A review of the History and Physical report completed on August 6, 2018, indicated Resident 103 was awake and alert. A review of the Initial Nursing Assessment dated August 3, 2018, indicated Resident 103 was incontinent of bowel and bladder and was not on a toileting program. The nursing assessment did not indicate the type of Resident 103's urinary incontinence. A review of the Minimum Data Set (MDS- a comprehensive assessment and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 106 of 144 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 10/05/2018 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 screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required total one person physical assistance with toilet use. The MDS indicated Resident 103 was always incontinent of urine and bowel. When asked the facility staff were unable to provide any care plan addressing Resident 103's bowel and urinary incontinence. A review of Resident 103's Documentation Survey Report (ADL flow sheet) indicated the resident had continent and incontinent episodes of urine and bowel from October 1, 2018 to October 3, 2018. On October 2, 2018 at 12:45 p.m., during an observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated that about an hour ago, he was in the Dining Room and requested to use the bathroom; a nurse took him to the nursing station and left him there. Resident 103 stated that he was staring at the walls while trying to get someone's attention, but everyone was just walking by him. After a while, the Physical Therapist Assistant (PTA 1) asked him if he needed help and he responded he needed to use the restroom. Resident 103 stated that he thought PTA 1 would take him to the restroom, but instead took him back to his room and told the resident he would get someone to help him. Resident 103 stated that after about 30 minutes, he soiled himself and was currently still soiled. Resident 103 stated that the nursing staff had not changed his incontinence brief yet. When asked how he felt about his concerns, resident stated that he felt sad and depressed. On October 2, 2018 at 1:06 p.m., during a follow-up interview, Resident 103 stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 107 of 144 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 10/05/2018 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 was able to feel the urge to urinate and that incontinence care was not being provided timely. On October 2, 2018 at 3 p.m., during an interview, PTA 1 stated that Resident 103 was by the nursing station around lunch time and verbalized that he wanted to use the restroom. PTA 1 stated that he took Resident 103 back to his room and told him that he would notify the nurse. PTA 1 stated that he notified Certified Nursing Assistant 7 (CNA 7). On October 3, 2018 at 7:24 a.m., during an interview, CNA 2 stated that Resident 103 would sometimes feel the urge to urinate or have a bowel movement. CNA 2 stated that Resident 103 had continent and incontinent episodes of bowel and bladder, but was mostly continent of bowel. On October 3, 2018 at 8:48 a.m., during an interview, CNA 7 stated that yesterday (October 2, 2018) around lunch time, Resident 103 was by the door of his room, sitting in his wheelchair and was trying to wheel himself inside the room. CNA 7 stated that Resident 103 looked "upset"; when asked if he needed help, Resident 103 responded that he was in the Dining Room and had requested someone to take him to the restroom; a staff brought him back, but did not help him with his toileting needs. CNA 7 stated that when she went to assist the Resident 103, the resident had already soiled himself. CNA 7 stated she spent some time trying to calm the resident down because he was pretty upset (crying). On October 4, 2018 at 12:19 p.m., during an interview, Licensed Vocational Nurse 11 (LVN 11) stated that the initial nursing assessment dated August 3, 2018, did not indicated what type of urinary incontinence Resident 103 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 108 of 144 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 10/05/2018 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 experiencing. LVN 11 stated that the nursing staff did not monitor Resident 103's voiding pattern , and she was unable to provide documented evidence Resident 103 had been placed on a bowel and bladder training program. LVN 11 stated Resident 103 should have been placed on a B&B training program, because he had continent and incontinent episodes of B&B. A review of the facility's revised policy dated March 1, 2018, titled "Continence Management" indicated a urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or readmission and with a change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. If a patient is incontinent, complete Urinary Incontinence Assessment and/or Bowel Retraining Assessment; address transient cause of incontinence; initiate Three-Day Continence Management Diary if incontinent is not resolved; develop plan of care based on information from assessment and diaries; implement revisions to the plan of care as needed; document daily toileting activity on ADL flow record, and use of absorbent products in care plan.

F691 SS=E Colostomy, Urostomy, or Ileostomy Care CFR(s): 483.25(f)

F691 11/05/2018 §483.25(f) Colostomy, urostomy,, or ileostomy care. The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 109 of 144 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 10/05/2018 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 the resident's goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 50 sampled residents (Resident 119), who was admitted with a colostomy (an operation that creates an opening for the large intestine, through the abdomen), received necessary care and services consistent with professional standards of practice and the resident's preferences by failing to: 1. Provide Resident 119 with colostomy selfcare instructions. 2. Provide colostomy care when requested by Resident 119. 3. Develop person-centered interventions indicating how and when to care for Resident 119's colostomy. As a result, Resident 119 was placed at a potential risk for skin irritation and infection at the colostomy site. Findings: A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable-the extent or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 110 of 144 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 10/05/2018 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 progression of, due to coverage of wound bed by dead or non-viable, not expected to heal, tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility, transfer, toilet use and personal hygiene. The MDS indicated Resident 119 had an ostomy (an artificial opening in an organ of the body). A review of the History and Physical (H&P) report completed on September 6, 2018, indicated that Resident 119 was alert and oriented. Resident 119 was admitted with diagnoses of metastatic colon cancer (spread of cancer cells from initial site of the disease to another part of the body). A review of the care plan initiated on September 10, 2018, indicated Resident 119 was incontinent of bowel and was unable to physically participate in a retraining program due to colostomy status. The care plan goal indicated Resident 119 will have incontinence care met by staff to maintain dignity and comfort and to prevent incontinence related complication. The care plan interventions included: apply moisture barrier to perianal (around the anus) and perineal (between the anus and the external genitalia) area as indicated, assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, and use absorbent product as needed. The care plan did not address necessary care specific to Resident 119's colostomy care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 111 of 144 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 10/05/2018 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 physician orders dated August 28, 2018, indicated to provide Resident 119 with the following colostomy services: 1. Colostomy appliance change as needed; 2. Colostomy appliance change every three days; 3. Colostomy care as needed; and 4. Colostomy care every shift A review of the Resident 119's Treatment Administration Record (TAR) from September 1, 2018 to October 4, 2018, did not indicate that the nursing staff provided colostomy care on an as needed basis. The TAR did not indicate the licensed nurses provided colostomy care on September 1, 4, 16, 20, 21, and 22, 2018 during the 3 p.m. to 11 p.m. shift. On October 2, 2018 at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff was ignoring him (resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, and colostomy bag timely, and did not empty his colostomy bag. Resident 119 stated that he was tired of asking the nursing staff to perform those tasks, because it made him feel like a child. Resident 119 stated that he sometimes emptied his own colostomy bag every two days, because some nursing staff did not want to empty it. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel "really sad." During the same interview at 11:33 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 112 of 144 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 10/05/2018 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 119 stated that he fell about 45 minutes ago, pressed the call light button two or three times, but no one came. Resident 119 stated he was attempting to go to the restroom to remove his incontinence brief and empty his colostomy bag. Resident 119 stated he landed on his right buttock wound and he heard a "pop" sound, then the wound started bleeding (the nurse had to apply deep pressure for about 10 minute). On October 2, 2018 at 12:19 p.m., during an interview, LVN 7 stated that Resident 119 emptied his own colostomy bag, because the resident knew how to care for his colostomy and preferred to care for it on his own. On October 4, 2018 at 10:37 a.m., during an observation, Resident 119 was lying in bed and LVN 6 was at the bedside administering medications. During a concurrent interview, Resident 119 stated that sometimes, he would change his colostomy bag and that when he asked some nurses to perform that task, they did not want to do it. Resident 119 stated that he did not receive any education/training from a facility staff on how to care for the colostomy. After Resident 119's statement, LVN 6, who was present during the interview, stated that it was the first time she was made aware that Resident 119 sometimes performed his own colostomy care. On October 4, 2018 at 12:07 p.m., during an interview, LVN 7 stated that Resident 119 told him (about the second week after admission) that he changed his colostomy bag. LVN 7 stated that he did not notify anyone, and did not document because he assumed the nurses knew, Resident 119 was changing his colostomy bag and performing colostomy care. LVN 7 reviewed Resident 119's care plan for bowel incontinence and stated that the care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 113 of 144 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 10/05/2018 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 plan did not address how to care for the resident's colostomy. On October 5, 2018 at 8:45 a.m., during an observation, Resident 119's colostomy bag was full and was leaking. On October 5, 2018 at 9 a.m., during an interview in the presence of the Administrator of the facility, Resident 119 stated that LVN 10 did not want to empty and/or change his colostomy bag yesterday (October 4, 2018). Resident 119 stated that he would change and/or empty his colostomy bag because some people did not want to do it. During the interview, Resident would become tearful at times and wipe his tears stating that he felt neglected, sad, and wanted "to be out of here", meaning out of the facility. Resident 119 stated that he did not know why the nurses were behaving like they did not care about the job, and that he was having a hard time as a resident in the facility. A review of the facility's revised policy dated March 1, 2018, titled "Person-Centered Care Plan" indicated a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary, in conjunction with the resident and/or resident representative, as appropriate, will establish the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.

F697 SS=D Pain Management CFR(s): 483.25(k) FORM CMS-2567(02-99) Previous Versions Obsolete

F697 Event ID: 985N11 11/05/2018 Facility ID: CA970000003 If continuation sheet 114 of 144 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 10/05/2018 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 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the nursing staff failed to provide pain management for one of 50 sampled residents (Resident 139), who verbalized having pain in her legs and stomach. This deficient practice resulted in Resident 139 not receiving pain medication and the potential to result in prolonged, unrelieved, unnecessary pain. Findings: A review of the admission record indicated Resident 139 was admitted into the facility on September 5, 2018, with diagnoses that included high blood pressure, heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), and anemia (lower-than-normal number of red blood cells or hemoglobin (a protein in the blood). A review of the History and Physical Report completed on August 8, 2018, indicated Resident 139 had the capacity to understand and make medical decisions. A review of Resident 139's Certificate of Terminal Illness dated September 5, 2018, indicated the resident was terminally ill and had a life expectancy of less than six months. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 115 of 144 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 10/05/2018 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 139 was awake, alert, and oriented to person, place, and time and complained of pain five out of 10 on a zero to 10 pain rating scale in her upper left abdomen. A review of the Minimum Data Set (a comprehensive assessment and care screening tool) dated September 12, 2018, indicated Resident 139 usually understood others and was usually able to make herself understood. The MDS indicated Resident 139 frequently complained of pain (five out of 10 on a zero to 10 pain rating scale, zero being no pain and 10 being the worst pain possible). A review of Resident 139's Pain Evaluation Form dated September 7, 2018, indicated the resident experienced chronic (long term) generalized pain (soreness) and that medication made the pain feel better. A review of Resident 139's physician orders indicated the followings: 1. Monitor for pain ever shift, dated September 5, 2018. 2. Acetaminophen Tablet 325 milligrams (mg), give two tablets by mouth as needed for mild pain not to exceed 3 grams, dated September 5, 2018. 3. Morphine Sulfate (Concentrate) solution 100 mg/5 milliliters (ml), give 0.25 ml by mouth every two hours as needed for mild pain, dated September 7, 2018. 4. Morphine Sulfate (Concentrate) solution 100 mg/5 ml, give 0.5 ml by mouth every two hours as needed for moderate pain, dated September 7, 2018. 5. Morphine Sulfate (Concentrate) solution 100 mg/5 ml, give 0.75 ml by mouth every two hours as needed for severe pain, dated September 5, 2018. 6. Norco Tablet 10-325 mg (HydrocodoneAcetaminophen), give one tablet by mouth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 116 of 144 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 10/05/2018 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 every four hours as needed for pain, dated September 5, 2018. A review of the care plan initiated on September 19, 2018, indicated Resident 139 exhibited or was at risk for alterations in comfort related to heart failure. The goal indicated Resident will achieve acceptable level of pain control for 90 days. The care plan interventions included, but were not limited to: evaluate pain characteristics: quality, severity, location, precipitating/relieving factors, medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated, and monitor for non-verbal signs/symptoms of pain and medicate as ordered On October 2, 2018 at 9:24 a.m., during an observation in the presence of Certified Nursing Assistant 4, Resident 139 was sitting in her wheelchair, awake, alert, and oriented to person and place. During a concurrent interview, Resident 139 stated that she was in pain 10 out of 10 (on a zero to 10 pain rating scale) and that her acceptable pain level was 4 -5 out of 10. When asked about the location of her pain Resident 139 responded legs and stomach. After interviewing Resident 139, CNA 4 was observed wheeling the resident out of the room and stated that she would notify the charge nurse of the resident's pain. A review of the Resident 139's Medication Administration Record did not indicate the resident received pain medication on October 2, 2018, during the 7 a.m. to 3 p.m. shift. On October 3, 2018 at 1:38 p.m., during an interview, CNA 4 stated she notified the charge nurse of Resident 139's pain on October 2, 2018, after the resident's interview with a survey team member. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 117 of 144 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 10/05/2018 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 On October 3, 2018 at 2:56 p.m., during an interview, Licensed Vocational Nurse 11 (LVN 11) stated CNA 4 notified him on October 2, 2018, at around 10 a.m. that Resident 139 was complaining of pain. LVN 1 stated that he assessed the resident, who stated that her pain was five out of 10. LVN 1 stated that he administered Sorbitol solution (indicated for constipation) and did not administer any medications (Morphine, Acetaminophen, or Norco) indicated for pain. LVN 1 stated that he should have provided pain management as ordered. A review of the facility's revised policy dated March 1, 2018, titled "Pain Management" indicated that pain management that is consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences is provided to patients who require such services. At a minimum of daily, patient will be evaluated for the presence of pain by making inquiry of the patient or by observing for signs of pain. Center staff will report any observation or communication of pain to the nurse responsible for that patient.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 10/05/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 118 of 144 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 10/05/2018 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 biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: c. On October 2, 2018 at 4:10 p.m. during an inspection of the over the counter Medication Storage Room in Station 1 accompanied by Registered Nurse 4 (RN 4) there was no room temperature thermometer. The storage room had medications such as Tylenol, vitamins, milk of magnesium, enemas, stool softeners, cough syrup, and vitamins. RN 4 stated she was not sure if the storage room should have a thermometer. RN 4 stated the staff from central supply was responsible for the storage room. During the inspection, there was an expired (April 2018) bottle of Iron Extended Release, 50 milligram tablets. RN 4 stated the staff from central supply was responsible for the storage room. On October 2, 2018 at 4:34 p.m. during an interview the Central Supply Staff 1 (CS 1) stated there was no thermometer in the over the counter medication storage room. CS 1 stated there was no need to have a thermometer in the over the counter medication storage room. CS 1 stated he checks the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 119 of 144 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 10/05/2018 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 medication storage every day and puts the expired medications in the incinerator (used for burning waste). CS 1 stated, "I missed the one you found". A review of the facility policy and procedure titled "Storage and Expiration, Dating of Medications, Biologicals, Syringes, and Needles" revised on October 31, 2016, indicated, the facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopoeia guidelines for temperature ranges (room temperatures 59 to 77 degrees Fahrenheit). The policy and procedure indicated the facility should ensure that medications and biologicals for expired, discharged, or hospitalized residents are stored separately, away from use, until destroyed or returned to provider. Based on observation, interview, and review of facility documents, the facility failed to store of drugs and biologicals in accordance with State and Federal laws for two of four medication storage rooms (Med Room 2, Med Room 1) and for one of one medication cart on the Transitional Care Unit by: 1. Failing to ensure that medication that had an expired date on the label, and medications for discharged or hospitalized residents were stored separately in a designated secure location and away from use until destroyed or returned to the dispensing pharmacy in Med Room 2. This deficient practice had the potential to result in nursing staff administering expired medications and/or medications of residents not currently residing in the facility. 2. Failing to ensure all medications and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 120 of 144 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 10/05/2018 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 biologicals were stored properly as evidenced by a medication cart on the Transitional Care Unit was observed to be unlocked and unattended. This deficient practice had the potential to allow residents, visitors, or unauthorized staff to have access to the medications belonging to one third of the residents of the Transitional Care Unit (approximately 11-12 residents). 3. Failing to ensure the storage room of the over the counter medications in Station 1 had a room thermometer. 4. Failing to ensure an expired over the counter medication was removed from the Storage Room in Station 1. These deficient practices placed the residents at risk of receiving expired and ineffective medications. Findings: a. On October 2, 2018 at 10:55 a.m., during inspection of Station 2 Medication Room (Med Room 2) in the presence of Licensed Vocational Nurse 6, (LVN 6) the followings were observed: 1. Resident 90's bag of Vancomycin (an antibiotic used to treat infection) was in the refrigerator, stored with other medication, and had an expiration date of September 20, 2018. During a concurrent interview, LVN 6 stated that it should disposed of "right away". A review of Resident 90's census indicated the resident was transferred out to the General Acute Care Hospital (GACH) on September 25, 2018, and transferred in from GACH on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 121 of 144 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 10/05/2018 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 September 30, 2018. 2. Resident 1A's bottle of Gabapentin (medication used to treat seizures) 250 milligrams (mg) per 5 milliliter (ml) solution was observed in the refrigerator. During a concurrent interview, LVN 6 stated that Resident 1A was transferred to GACH about three weeks ago and that the Gabapentin should have been returned to the pharmacy or disposed of. A review of Resident 1A's census indicated the resident was transferred out to the GACH on August 28, 2018, and discharged to the GACH on September 4, 2018. 3. Resident 2A's boxes (two) of Lovenox (helps prevent the formation of blood clots) 40 mg were stored on the counter. During a concurrent interview, LVN 6 stated that Resident 2A was transferred to GACH about a week ago, and that the nursing staff should have disposed the two boxes of Lovenox immediately. A review of Resident 2A's census indicated the resident was transferred out to the GACH on September 28, 2018. A review of the facility's revised policy dated October 31, 2016, titled "Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles" indicated that the facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The facility should ensure that medications or biologicals for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 122 of 144 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 10/05/2018 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 expired, or discharged, or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider. The facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other Applicable Law. The facility personnel should inspect nursing station storage areas for proper storage compliance on a regular scheduled basis. A review of the facility's revised policy dated June 30, 2016, titled "Disposal/Destruction of Expired or Discontinued Medication" indicated that the facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. b. During initial tour of the Transitional Care Unit (TCU) on 10/02/18 at 7:15 AM the Medication Cart was observed unattended and with the lock button extended. During a subsequent interview with Licensed Vocational Nurse (LVN 4) on 10/02/18 at 7:17 a.m., LVN 4 was able to open the cart without the keys. LVN 4 stated, "The LVN is giving report. The cart should be locked." LVN 4 stated there were three medication carts on the unit. During an interview with Registered Nurse (RN 1) on 10/02/18 7:39 AM, she stated, "The med cart should be locked when the LVN is not present." The facility policy and procedure titled "5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles" and dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 123 of 144 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 10/05/2018 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 April 11, 2018, indicated "3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors."

F790 SS=D Routine/Emergency Dental Srvcs in SNFs CFR(s): 483.55(a)(1)-(5)

F790 11/02/2018 §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facility§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; §483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; §483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 124 of 144 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 10/05/2018 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 within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. This REQUIREMENT is not met as evidenced by: b. On October 4, 2018 at 9:32 a.m., Resident 353 was observed laying in bed and stated she has been asking to see a dentist since admission. The resident stated she had difficulty chewing food. The resident was observed with broken and missing teeth. A review of the admission record indicated Resident 353 was initially admitted on September 17, 2018, with diagnoses including hypertension (high blood pressure), and urinary tract infection (an infection that begins in the urinary system). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated September 24, 2018, indicated Resident 353's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 353 required extensive assistance for moving in bed, transferring from bed to chair, dressing, toilet use and personal hygiene. The MDS indicated Resident 353 did not have any dental issues such as obvious or likely cavity or broken natural teeth. On October 4, 2018 at 2:33 p.m., during a concurrent record review and interview Registered Nurse 4 (RN 4) confirmed the oral/dental assessment indicated Resident 353 had no dental problems. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 125 of 144 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 10/05/2018 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 On October 4, 2018 at 2:50 p.m., during a concurrent observation and interview, RN 4 and RN 5 (the MDS nurses) assessed Resident 353 and confirmed the resident's dental status was not accurately reflected in the assessment. RN 5 agreed the MDS was not coded correctly because Resident 353 had broken and missing teeth. On October 4, 2018 at 3:05 p.m. during an interview Licensed Vocational Nurse 12 (LVN 12) stated the past Sunday (September 30, 2018) Resident 353 told her she wanted to have her teeth fixed. LVN 12 stated she told Resident 353 she will inform the social worker to help make the arrangement for the dentist. On October 4, 2018 at 3:35 p.m. during an interview Social Worker (SW 1) stated she did not send a request for the resident to be seen by the dentist. SW 1 stated "I slipped on this one". SW 1 stated will informed the dentist to see the resident tomorrow. A review of the facility policy and procedure titled "Dental Services" revised on July 24, 2018, indicated the health care center will provide or obtain from an outside resource routine and emergency dental services , including 24 hour emergency dental care, to meet the needs of each patient. The policy and procedure indicated emergency dental services included services needed to treat an episode of acute pain in teeth, gum or palate; broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Based on observation, interview, and record review, the facility failed to ensure two of 50 sampled residents (Resident 103 and 353) received routine dental services to meet the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 126 of 144 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 10/05/2018 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 needs of the resident by: 1. Failing to ensure Resident 103 was provided dental services as ordered by the physician. 2. Failing to ensure Resident 353 was provided dental services for broken and missing teeth. These deficient practices resulted in a delay of necessary dental care for Resident 103 and 353, and placed the residents at risk for gum and teeth diseases and can lead to altered nutritional status such as weight loss. Findings: a. A review of the admission record indicated Resident 103 was admitted to the facility on August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region, and abnormal gait and mobility. A review of the History and Physical report completed on August 6, 2018, indicated Resident 103 was awake and alert. A review of Resident 103's physician order dated August 3, 2018, indicated to provide a dental consult and treatment as needed for the resident's health and comfort. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required limited one person physical assistance with eating. The MDS indicated Resident 103 had obvious or likely cavity or broken natural teeth. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 127 of 144 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 10/05/2018 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 On October 2, 2018 at 12:53 p.m., during an observation, Resident 103 was sitting in his wheelchair and eating independently. During a concurrent interview, Resident 103 stated that he had not seen a dentist since admission (August 3, 2018) into the facility. On October 4, 2018 at 3:07 p.m., during an interview, the Social Service Director (SSD 1) stated that after admission, the Social Service Department would submit the list of residents (regardless of whether or not they complain of dental issues), requiring dental consult. The dentist would then examine the residents during the next scheduled visit. The SSD stated she was unable to provide documented evidence the dentist examined Resident 103. The SSD stated that Resident 103 should have received routine services. On October 4, 2018 at 3:40 p.m., during a follow-up interview, Resident 103 stated that he had some missing lower teeth. When Resident 103 opened his mouth, missing teeth were noted on the lower right corner of the resident's gums. A review of the facility policy dated November 28, 2017, titled "Dental Services" indicated the facility will provide or obtain from an outside resource routine and emergency dental services, including 24-hour emergency dental care to meet the needs of each resident.

F803 SS=D Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 11/02/2018 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 128 of 144 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 10/05/2018 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 §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure meals were prepared to meet the needs of one of 31 sampled residents (Resident 29). For Resident 29, the facility failed to ensure the resident did not receive peaches on his food tray after he informed staff he had an allergy, which had a potential to cause the resident to have an allergic reaction. Findings: A review of the Resident 29's admission record dated 10/4/18, and timed 11:59 a.m., indicated the resident was initially admitted on 10/7/16 and his last readmission was 6/29/18, from a general acute care hospital. The resident's diagnoses included neck fracture, end stage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 129 of 144 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 10/05/2018 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 renal disease (a condition where kidneys lose the ability to filter waste from your blood sufficiently),with dependence on renal dialysis (a treatment process that removes excess water and toxins from the body), diabetes mellitus (high blood sugar) and bipolar disorder (a serious mental illness characterized by extreme mood swings). A review of the Resident 29's Minimum Data Set (MDS - a comprehensive assessment and care planning tool), dated 7/7/18, indicated the resident had adequate hearing and vision and was able to speak clearly. Resident 29 was able to express ideas and wants, understand verbal content, and had no likely cognitive impairment. During an observation on 10/3/18 at 7:30 a.m., Resident 29 was sitting in his room with his breakfast tray. The resident's food was all consumed, except for his peaches. Resident 29 stated, "I'm allergic to peaches, I get hives. I don't want to take a risk." The resident stated that he had never told anyone because "I don't want to complain. I just push them to the side because I don't want to take a risk" Resident 29 was then observed informing Licensed Vocational Nurse 1 (LVN 1) that he was allergic to peaches and LVN 1 stated, "I'll make sure to tell dietary (services) not to give you peaches." During an interview with LVN 1 on 10/3/18 at 7:40 a.m., he stated, "Resident 29 has never told me he was allergic to peaches, and his electronic health record (eHR) indicates he doesn't have any allergies." During an interview on 10/4/18 at 8:15 a.m., Resident 29 stated, "There were peaches on my breakfast tray this morning. I didn't want to complain, so I just pushed them aside, but I don't want to risk getting hives." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 130 of 144 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 10/05/2018 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 Resident 29's eHR on 10/4/18 at 8:17 a.m. indicated "No known allergies" for Resident 29. During an interview with LVN 1 on 10/4/18 at 8:20 a.m., he stated he notified dietary (services) by giving them a dietary communication slip. LVN 1 immediately reviewed Resident 29's clinical record and was able to find the yellow copy of a dietary communication slip dated 10/3/18 and timed 8:10 a.m., that indicated Resident 29 had an allergy to peaches. During an interview with the Kitchen and Dietary Manager (KDM) and the Dietary Assistant (DA) on 10/4/18 at 8:25 a.m., the KDM stated a resident is to be assessed on admission for allergies, and "Nursing will notify us of diet changes by filling out a dietary communication slip and putting the white original copy in the basket by the elevator. We did serve canned peaches for breakfast today." During the same interview the DA stated, "I will pick up the slips, and make the changes to the resident diet cards every day. Then I staple all of the slips together. I did not get a slip yesterday for Resident 29." The DA reviewed a stack of dietary communication slips that were dated 10/3/18, and was unable to find the corresponding white slip to the yellow slip provided by LVN 1. A review of Resident 29's eHR on 10/4/18 at 11:59 a.m., indicated the resident had an allergy to "Peach." The facility's policy and procedure titled "NSG201 Allergic/Adverse Reactions", dated 3/1/18, indicated the facility should "Record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 131 of 144 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 10/05/2018 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 allergies/adverse reaction in the medical record" and "If the patient has a food allergy, notify Food and Nutrition Services."

F804 SS=E Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 11/02/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure food served was palatable and/or at the proper temperature for eight of 50 sampled residents (Residents 103, 139, 119, 92, 85, 82, 53 and 100) and for six out of seven residents in attendance during the Group Meeting. This deficient practice had the potential to impact the resident's nutritional status, quality of life and can lead to insufficient food intake. Findings: On October 3, 2018 at 10:10 a.m., during a group meeting interview, six out of seven residents in attendance complained that the food was served cold. a. A review of the admission record indicated Resident 119 was originally admitted to the facility on August 28, 2018, and readmitted in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 132 of 144 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 10/05/2018 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 September 15, 2018, with diagnoses that included muscle weakness, difficulty in walking, malignant neoplasm of colon (cancer of the large intestine), malignant neoplasm of rectum (cancer of the rectum), colostomy status (an operation that creates an opening for the large intestine, through the abdomen), and pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left and right buttocks, unstageable (known but not stageable due to coverage of wound bed by dead or non-viable tissue). A review of the Minimum Data Set (MDS- a comprehensive and care screening tool) dated September 4, 2018, indicated Resident 119 had intact cognition. A review of Resident 119's History and Physical (H&P) report completed on September 6, 2018, indicated the resident was alert and oriented. On October 2, 2018 at 12:11 p.m., during an interview, Resident 119 stated that the food always arrived cold, did not taste good, and that he liked to eat food that was hot. A review of the facility's revised policy dated August 8, 2018, titled "Food Handling" indicated all Time/Temperature Control for Safety Food must maintain an internal temperature of 41 degree Fahrenheit or lower, or 135 degree Fahrenheit or higher while being held for service. During transportation of food from the kitchen to the dining rooms, patient/resident rooms, or other dining locations, care is taken to keep hot food hot and cold food cold and protected from contamination. b. A review of the admission record indicated Resident 103 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 133 of 144 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 10/05/2018 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 August 3, 2018, with diagnoses that included hemiplegia (paralysis of one side of the body), muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region, and abnormal gait and mobility. A review of Resident 103's History and Physical report completed on August 6, 2018, indicated the resident was awake and alert. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated August 10, 2018, indicated Resident 103 had intact cognition and required limited one person physical assistance with eating. On October 2, 2018 at 1:01 p.m., during an observation, Resident 103 was sitting in his wheelchair and eating his lunch. During a concurrent interview, Resident 103 stated he was a former chef and that the food served (at the facility) was not good most of the time. Resident 103 stated the macaroni and cheese had no flavor, the spaghetti and meat sauce were not cooked properly, and the Dietary Department provided a lot of starchy food in one meal (spaghetti, beans, bread), which contributed to elevated blood sugar. Resident 103 stated he could tell the food was not good because a lot of residents would leave their food on the tray (not eaten). c. A review of the admission record indicated Resident 139 was admitted into the facility on September 5, 2018, with diagnoses that included high blood pressure, heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), and anemia (lower-than-normal number of red blood cells or hemoglobin in the blood). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 134 of 144 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 10/05/2018 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 Minimum Data Set (a comprehensive assessment and care screening tool) dated September 12, 2018, indicated Resident 139 usually understood others and was usually able to make herself understood. The MDS indicated Resident 139 received a mechanically altered diet (require change in texture of food or liquid). On October 2, 2018 at 9:24 a.m., during an observation, Resident 139 was sitting in her wheelchair, awake, alert, and oriented to person and place. During a concurrent interview, Resident 139 stated she did not like the food (taste), did not eat, and did not ask for a substitute. d. A review of the admission record indicated Resident 92 was admitted into the facility on July 27, 2018, with diagnoses that included muscle weakness, difficulty in walking, and paraplegia (paralysis of the lower part of the body, including the legs). A review of the MDS dated August 3, 2018, indicated Resident 92 had intact cognition and required supervision, set up with eating. On October 3, 2018 at 3:21 p.m., during an interview, Resident 92 stated that the food was cold and freezing. Resident 92 stated that sometimes, the meal trays would be in the carts for about 20 minutes because the CNAs only looked for trays of their assigned residents. e. On October 2, 2018 at 8:06 a.m., during a tour of the facility Resident 85 stated the food did not taste good and was cold most of the time. A review of the admission record indicated Resident 85 was admitted on July 21, 2017, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 135 of 144 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 10/05/2018 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 with diagnoses including but not limited to diabetes mellitus (high blood sugar) and major depressive disorder. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated August 15, 2018, indicated Resident 85's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. f. On October 2, 2018 at 11:29 a.m., during a tour of the facility Resident 82 stated the food was sometimes cold and he had to ask the staff to warm it up. Resident 82 stated the oatmeal and the eggs are often cold and cold food made him vomit. A review of the admission record indicated Resident 82 was admitted on August 9, 2018, with diagnoses including but not limited to diabetes mellitus (high blood sugar) and osteomylitis (infection of the bone). A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated August 16, 2018, indicated Resident 82's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were intact. g. A review of the facility's Resident Council Meeting minutes dated 8/13/18, indicated Resident 53 stated that the food had been arriving cold and at times late, especially during the weekends. The response from the Dietary Department indicated that "These issues were more likely to do with when the trays are passed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 136 of 144 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 10/05/2018 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 facility's Resident Council Meeting minutes dated 9/10/18, indicated Resident 100 stated that dinner was being served late. The response from the Dietary Department indicated that "There may be different timing from the time we deliver and when the trays are actually passed out by CNA's." During a breakfast tray line observation on 10/4/18 at 7:45 a.m., with the Kitchen and Dietary Manager (KDM), the trays for Station 4 were prepared and placed on the delivery cart. A test tray for pureed diet was immediately provided by the kitchen staff. The Station 4 trays were then inspected by a registered nurse and the Dietary Director (DD). The KDM stated they were checking the trays for accuracy. At 10/4/18 at 8:20 a.m., the Station 4 tray inspection was completed and the delivery cart was observed leaving the kitchen on route to Nursing Station 4. During a temperature check with KDM at the same time (using the facility's calibrated food thermometer), the temperature of the food on the Station 4 test tray was as follows: Milk (in a plastic cup with plastic cover) - 60 degrees Fahrenheit (F) Oatmeal (in a plastic bowl with plastic cover) 80 degrees F Pureed Bread (on plate underneath plate cover) - 100 degrees F Scrambled eggs (on plate underneath plate cover) - unable to measure due to texture On 10/4/18 at 8:34 a.m., the last of the Station 4 trays was observed being delivered to the residents. During a temperature check with Dietary Supervisor at the same time, the temperature of the food on the test tray were as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 137 of 144 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 10/05/2018 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 Milk (in a plastic cup with plastic cover) - 60 degrees F Oatmeal (in a plastic bowl with plastic cover) 80 degrees F Pureed Bread (on plate underneath plate cover) - 95 degrees F On 10/4/18 at 8:34 a.m., a taste test of the tray with Dietary Supervisor indicated not all the food was served at an appetizing temperature. The Dietary Supervisor stated that the milk was "okay," but the bread and eggs were "room temperature" and the oatmeal was "cold." The Dietary Supervisor stated the temperature from the time the food left the kitchen to completion of delivery to residents was only a little different, but the food was not at a pleasing temperature. The facility policy and procedure titled "4.7 Food Handling" dated 8/8/18, indicated under "Food Safety During Meal Preparation and Service" that "24. During transportation of food from the kitchen to the dining rooms, patient/resident rooms, or other dining locations, care is taken to keep hot food hot and cold food cold and protected from contamination."

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 11/02/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 138 of 144 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 10/05/2018 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 different meal choice; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 50 sampled residents (Resident 139) would not receive eggs with her breakfast as indicated on the resident's meal ticket. This deficient practice resulted in the Dietary Department not honoring Resident 139's food preference and had the potential to negatively affect the resident's nutritional status. Findings: A review of the admission record indicated Resident 139 was admitted into the facility on September 5, 2018, with diagnoses that included high blood pressure, heart failure (a condition in which the heart can't pump enough blood to meet the body's needs), and anemia (lower-than-normal number of red blood cells or hemoglobin in the blood). A review of the Minimum Data Set (a comprehensive assessment and care screening tool) dated September 12, 2018, indicated Resident 139 usually understood others and was usually able to make herself understood. The MDS indicated Resident 139 received a mechanically altered diet (require change in texture of food or liquid). On October 3, 2018 at 8:06 a.m., during an observation, Resident 139 was in bed eating breakfast. Resident 139's breakfast tray included scrambled eggs. The meal ticket indicated "NO EGGS". During a concurrent interview, Resident stated that she did not like/eat eggs and requested someone to come FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 139 of 144 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 10/05/2018 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 take the eggs off her plate. On October 3, 2018 at 8:08 a.m., during an interview, Registered Nurse 2 (RN 2) stated that Resident 139 was not supposed to receive eggs on her plate as directed on the meal ticket. RN 2 was observed to go inside Resident 139's room, ask the resident if she wanted the eggs, and the resident responded no. RN 2 then removed the eggs from the resident's plate.

F812 SS=C Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 10/26/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, facility failed to ensure foods are stored and prepared under sanitary conditions as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 140 of 144 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 10/05/2018 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 1) an open container of salad dressing was observed in the dry storage room. 2) the sanitizing bucket quaternary solution level (a solution used for sanitization) was not properly documented on two separate days. These deficient practices had the potential to cause the facility resident's to contract food borne illnesses (illness caused by consuming contaminated foods or beverages) from food stored and prepared in unsanitary conditions. Findings: a. During an initial tour of the kitchen areas with the Kitchen and Dietary Manager (KDM) on 10/2/18 at 7:23 a.m., an open plastic container of salad dressing was observed on the shelf in the dry storage room. During a concurrent interview on 10/2/18 at 7:23 a.m., the KDM stated, "I think they just removed it from the freezer, but they shouldn't have placed it here." The facility policy and procedure titled "5.7 Refrigerated/Frozen Storage" dated October 1, 2015, indicated "1.2 Refrigerated foods are stored immediately upon delivery." The facility policy and procedure titled "4.7 Food Handling" date 8/8/18, indicated under "Food Safety During Meal Preparation and Service" that "9. Food that is removed from the refrigerator for preparation is processed immediately." b. During an initial tour of the kitchen areas with the Kitchen and Dietary Manager (KDM) on 10/2/18 at 7:26 a.m., a review of the "Quat [ernary] Log" for September to October 2018, indicated that Kitchen Staff (KS 1) had written that day's date and the time "6:30" and his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 141 of 144 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 10/05/2018 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 initials, but no box was checked to indicate the quaternary solution reading at that time. During a concurrent interview with KDM on 10/2/18 at 7:26 a.m., she stated the sanitizing bucket is used to sanitize food preparation and serving areas and should be checked at the beginning of the shift, "whenever it looks dirty", and the morning staff should have recorded the test reading that morning at 6:30 a.m., when the log was signed. On 10/2/18 at 7:30 a.m., the KDM used the quaternary test strips to check the solution strength. The color of the strip corresponded to the test strip packaging as 150 parts per million (ppm). This reading was validated by the KDM. During a follow up tour of kitchen areas on 10/4/18 at 7:10 a.m., a review of the "Quat Log" for September to October 2018, indicated that the Kitchen Staff (KS 1) had written that day's date and the time "6:30" and his initials, but no box was checked to indicate the reading at that time. The KDM stated that the test reading should have been marked, but KS 1 had not done it again. The facility policy and procedure titled "4.3 Manual Warewashing and Sanitizing" dated 6/15/16, indicated: 3. If chemically sanitizing, the Director of Dining Services / Director of Culinary Services or designee tests the solution strength during each period using quaternary test strips. 3.3 The color of the strip is checked against the strip container. The test strip will darken to the range of 200-400 ppm (unless a different range is indicated by the manufacturer) for the proper solution strength. 3.4 If test strip does not turn the appropriate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 142 of 144 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 10/05/2018 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 darkness, corrections are made before the sanitizing process can take place. 3.5 The result of the test is recorded on the Manual Warewashing Sanitation Log at each wash period.

F914 SS=D Bedrooms Assure Full Visual Privacy CFR(s): 483.90(e)(1)(iv)(v)

F914 11/02/2018 §483.90(e)(1)(iv) Be designed or equipped to assure full visual privacy for each resident; §483.90(e)(1)(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 50 sampled residents (Resident 300) was provided with a ceiling suspended curtain, which extends around the bed to provide total visual privacy. This deficient practice violated Resident 300's right to privacy and had the potential to negatively affect the resident's psychosocial well-being. Findings: A review of the admission record indicated Resident 300 was admitted to the facility on September 30, 2018, with diagnosis that included muscle weakness, difficulty in walking, high blood pressure, and diabetes (uncontrolled blood sugar). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 143 of 144 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 10/05/2018 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 History and Physical report completed on October 3, 2018, indicated that Resident 300 was awake, alert, and oriented to person, place, and time. On October 5, 2018 at 4:55 p.m., during an observation. Resident 300 was up in a chair by the foot of the bed. A ceiling suspended privacy curtain was not noted. During a concurrent interview, Resident 300 stated there had not been any curtain since his admission into the facility. On October 5, 2018 at 4:57 p.m., during an interview, regarding Resident 300's curtain, the Housekeeper Supervisor (HS) stated that he would provide a privacy curtain. On October 5, 2018 at 4:59 p.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated that she provided wound treatment earlier during the day and did not notice the resident did not have privacy curtain. A review of the facility's revised policy dated November 28, 2016, titled "Privacy Rights: Patient" indicated that the patient has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes accommodations, medical treatment, written, telephone and electronic communications, personal care, visits, and meeting family and patient groups. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 985N11 Facility ID: CA970000003 If continuation sheet 144 of 144