The Seasons at Alexandria

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policies, the facility failed to ensure food items located in dry storage, the walk-in refrigerator, the number five kitchen reach-in refrigerator, and unit nourishment refrigerators were properly labeled and dated, and that expired food items were discarded. This deficient practice affected all 99 current residents.The findings include:Review of the facility's policy titled, Food and Supply Storage, revised 01/2024 revealed foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. Further review revealed unused portions and opened packages of food should be covered, labeled, and dated.Observation during an initial brief kitchen tour on 08/12/2025 at 10:53 AM revealed one pork ham with a discard date of 08/11/2025 located in the walk-in refrigerator; an undated, opened package of devil's food cake mix, an undated, opened 11 pound tub of chocolate fudge icing, and an expired loaf of bread located in dry storage; and an expired container…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's document and policies, the facility failed to ensure medications designed for multiple administrations were labeled to identify the specific resident for whom it was prescribed and/or the date the medication was opened in 1 of 7 sampled medication carts for the Maple Unit. Additionally, the facility failed to ensure the provision of appropriate environmental controls to preserve the integrity of medications in 1 of 7 sampled medication refrigerators, the Maple Unit medication storage refrigerator. Also, the facility failed to ensure when medications were prepared or compounded for use, a label containing the required information was attached to the compounded medication label for 1 of 1 sampled resident, Resident (R) 56 The findings include:Review of the facility's policy titled, General Dose Preparation and Medication Administration, last revised date [DATE], revealed staff should enter the date opened on the label of medications with shortened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal and oral hygiene for 1 of 2 residents investigated for ADLs, Resident (R) 122.The findings include:Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 10/23/2024, revealed, The facility will provide care and services for activities of daily living including, bathing, dressing, grooming and oral care. Further review revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R122's admission Record revealed the facility admitted the resident on 08/08/2025 with diagnoses including COVID-19 and syncope.Review of R122's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/15/2025, revealed the facility assessed to resident to have a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure residents' food was served in a safe manner, and ensure all staff practiced proper hand hygiene procedures during the supper meal service on 05/28/2024. Observation of the supper meal on 05/28/2024, revealed State Tested Nurse Aide (STNA)7 failed to wash her hands with soap and water, dry her hands thoroughly with a single-use towel, and turn off the faucet with a clean towel while serving residents' supper meal trays. The findings include: Review of the facility's policy titled, Hand Hygiene, implemented 11/08/2022, revealed, Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub [ABHR]. Continued review revealed Hand hygiene technique when using soap and water: Wet hands with water. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hand and fingers. Rinse hands with water.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the Centers for Disease Control and Prevention Infection Prevention during Blood Glucose Monitoring and Insulin Administration, and Environmental Cleaning Procedures: Best Practices for Environmental Cleaning in Healthcare Facilities, review of the manufacturer's instructions for use, review of [NAME] (2014) Manual of Nursing Practice 10th edition, and review of the facility's policies and procedures, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. The facility also failed to help prevent and control the development and transmission of communicable diseases and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health's (Health Department) state guidelines for COVID-19. Observations, on 05/24/2022 before lunch, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to handle kitchen equipment in a sanitary manner in the dish room. Observations, on 05/24/2022, of Utility Aide #1 revealed he touched the clean top and bottom covers for clean plates with contaminated ungloved hands. The findings include: Review of the facility's policy titled, Sanitation and Infection Prevention/Control: Hand Hygiene, dated 01/2022, revealed, under Disposable, that non-latex gloves must be worn when handling soiled dishware, clean utensils, dishes, and equipment. Per the policy, hands must be washed before putting on and after removing disposable gloves when working in the kitchen. Further, it stated disposable gloves must be changed and hands washed when the gloves were dirty and when moving from one task to another; for example, from handling dirty dishes to handling clean dishes. Observation of Utility Aide #1, on 05/24/2022 at 9:30 AM, revealed he was in the dish room and walked from the soiled side of the dishwasher, handled the soiled dishware, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to provide food and drink that is palatable, and at a safe and appetizing temperature. Observations of test trays from the breakfast meal on 05/16/19 on the [NAME] Unit, Hickory Unit, and Walnut Unit, revealed point of service temperatures for hot foods were below one hundred thirty-five (135) degrees Fahrenheit (F) which was not in accordance with facility policy. In addition, point of service temperatures were observed above forty (40) degrees F for cold foods, which was not in accordance with facility policy. The findings include: Review of the facility Policy titled, Meal Service: Taste & Temperature Control/Food Holding, dated 01/2016 revealed food is maintained at proper temperatures during service to meet resident expectation for palatability and to ensure food safety principles are maintained to prevent foodborne illness. Continued review of the Policy, revealed cold foods such as milk,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the walk-in refrigerator in the kitchen, on 05/04/19, revealed two (2) one (1) gallon jars of sweet pickle relish which were open and undated. In addition, observation of the stand-up refrigerator in the kitchen, on 05/04/19, revealed one (1) sixteen (16) ounce bottle of mayonnaise with the cap broken off. The findings include: Review of the facility Policy, titled Receiving & Storage, dated 01/2016, revealed it was the policy of the facility that proper procedures will be utilized for all dry and refrigerated food storage. Further review revealed all items are dated when received. Continued review revealed products must be checked to detect unacceptable items. Observation on 05/14/19 at 10:31 AM, of the walk-in refrigerator in the kitchen, revealed two (2) one (1) gallon jars of North Star Pickle Company sweet relish that had been opened, but were not dated with the open date. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility's Policy, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was revised for one (1) of twenty three (23) sampled residents (Resident #91). Resident #91's indwelling urinary catheter was discontinued on 04/26/19 as per Physician's Orders; however, the CCP was not revised related to the discontinuation of the Foley catheter. The findings include: Review of the facility's Policy, titled Care Plan, dated 10/18/18, revealed the individualized CCP would include measurable goals and periods to meet each resident's medical, physical and psychosocial need that is identified during the assessment. A complete re-evaluation is performed at least quarterly, or with any significant change. Additionally, each residents CCP is updated based on the target dates used for each goal by the interdisciplinary team, as well as any time the plan of treatment or resident needs dictate. Review of Resident #91's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's Policies, it was determined the facility failed to ensure hand hygiene procedures were followed by staff involved in direct resident contact. Observation on 05/14/19 of Dietary Aide #5, during afternoon meal service on the Maple Unit, revealed the Aide touched multiple objects and surfaces, then failed to perform hand hygiene and don new gloves prior to returning to food service. The findings include: Review of the facility's Infection Control Guidelines, Policy, reviewed 10/31/17, revealed it was facility policy to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Further review revealed all staff shall wash their hands after handling contaminated objects. Observation on 05/14/19 at 11:50 AM, on the Maple Unit, revealed Dietary Aide #5 opened the dishwasher and reached into the dishwasher with gloved hands and retrieved a knife. Dietary Aide #5 failed to perform hand hygiene and don new gloves before cutting a resident's sandwich.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.