Inspection Reports for
The Seasons at Alexandria
7341 E ALEXANDRIA PIKE, ALEXANDRIA, KY, 41001
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
150% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Census: 99
Deficiencies: 2
Date: Aug 15, 2025
Visit Reason
The inspection was conducted due to a confirmed case of Legionnaires' disease in a resident (R121) and concerns about the facility's infection prevention and control program, specifically related to Legionella contamination in the water system.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, including a water management program to prevent Legionella growth. Testing revealed uncontrolled Legionella growth in the hot shower of a resident's room and the cooling tower. Additionally, staff failed to properly disinfect shared blood glucose monitoring equipment according to policy.
Deficiencies (2)
F 0880 Infection Control: The facility failed to provide and implement an infection prevention and control program to prevent communicable diseases and infections for the total census of 99 residents, including failure to have a water management program prior to Legionella detection.
Failure to properly clean and disinfect a shared glucometer according to the manufacturer's instructions and recommended disinfectant dwell time, risking cross-contamination among residents.
Report Facts
Resident census: 99
Legionella colony-forming units (CFUs): 66
Legionella colony-forming units (CFUs): 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Failed to properly disinfect glucometer |
| RN 6 | Registered Nurse | Provided staff education on Legionella |
| Director of Nursing | Director of Nursing | Discussed Water Management Program and infection control expectations |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and involved in infection control response |
| Certified Legionella Expert | Consultant | Developed Water Management Program and conducted water testing |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 4
Date: Aug 15, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including infection control, medication management, food safety, and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide necessary ADL assistance to a COVID-positive resident, improper medication labeling and storage, expired and unlabeled food items, and a failure to maintain an effective infection prevention and control program, including inadequate Legionella water management leading to immediate jeopardy.
Deficiencies (4)
F0677: The facility failed to ensure a resident unable to perform ADLs received necessary grooming and hygiene services, specifically denying a shower to a COVID-positive resident based on outdated protocols.
F0761: The facility failed to label medications with resident identification and date opened, failed to maintain proper refrigerator temperatures, and failed to label compounded medications properly.
F0812: The facility failed to ensure food items were properly labeled, dated, and expired items discarded, affecting all 99 residents.
F0880: The facility failed to establish and maintain an infection prevention and control program, resulting in immediate jeopardy due to Legionella contamination in the water system and improper disinfection of shared glucometers.
Report Facts
Residents affected: 1
Residents affected: 7
Residents affected: 99
Residents affected: 99
Medication refrigerator temperature: 20
Refrigerator temperature range: 36
Refrigerator temperature range: 46
Legionella colony-forming units: 66
Legionella colony-forming units: 1500
Facility census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN3 | Registered Nurse | Named in observation of improper glucometer disinfection |
| RN4 | Registered Nurse | Named in interviews regarding ADL assistance and COVID protocols |
| STNA4 | State Tested Nurse Aide | Named in interviews regarding ADL assistance and COVID protocols |
| LPN4 | Licensed Practical Nurse | Named in interview regarding medication preparation and labeling |
| LPN6 | Licensed Practical Nurse | Named in interview regarding medication preparation and labeling |
| DON | Director of Nursing | Named in multiple interviews regarding facility policies and deficiencies |
| Administrator | Facility Administrator | Named in multiple interviews regarding facility policies and deficiencies |
| IP | Infection Preventionist | Named in interviews regarding Legionella testing and infection control |
| Medical Director | Medical Director | Named in interviews regarding infection control and facility expectations |
| CLE | Certified Legionella Expert | Named in interview regarding Legionella testing and water management |
Inspection Report
Enforcement
Deficiencies: 2
Date: Aug 14, 2024
Visit Reason
The inspection was conducted due to an Immediate Jeopardy situation involving failure to develop and implement comprehensive person-centered care plans and inadequate supervision of residents, specifically related to an incident where a resident was left unsupervised outside in extreme heat resulting in hospitalization.
Findings
The facility failed to develop and implement comprehensive care plans with measurable objectives for residents and did not ensure adequate supervision to prevent accidents. A resident was left unattended outside in 90-degree weather for 30 to 45 minutes, resulting in heatstroke and hospitalization. Immediate Jeopardy was identified and later removed, but non-compliance remained.
Deficiencies (2)
42 CFR 483.21 (F656) The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for five sampled residents. No care plans or interventions were in place for supervision when residents were outdoors.
42 CFR 483.25 (F689) The facility failed to ensure adequate supervision to prevent accidents, resulting in one resident being left unattended outside in extreme heat for 30 to 45 minutes, causing heatstroke and requiring emergency hospitalization.
Report Facts
Resident temperature: 105
Resident temperature: 102.7
Resident temperature: 99.4
Resident BIMS score: 11
Resident BIMS score: 13
Resident BIMS score: 13
Resident BIMS score: 9
Resident BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | LPN | Reported resident R4's condition and assisted with emergency care during heatstroke incident |
| STNA40 | State Trained Nurse Assistant | Assisted resident R4 outside and was involved in supervision failure leading to heatstroke |
| Clinical Coordinator 1 | Clinical Coordinator | Provided information on facility supervision policies and incident awareness |
| Director of Nursing | DON | Discussed facility supervision policies and acknowledged lack of formal policy |
| Administrator | Facility Administrator | Provided statements on supervision practices and plans for process review |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The investigation was conducted due to allegations of physical and verbal abuse by staff towards residents, specifically incidents involving State Tested Nurse Aide (STNA) 9 and residents R24 and R11.
Complaint Details
The complaint investigation was substantiated. Immediate Jeopardy was identified on 05/31/2024 related to abuse and neglect. The facility was notified and an Immediate Jeopardy Removal Plan was accepted and validated on 06/06/2024. Non-compliance remained at a lower severity while monitoring continued.
Findings
The facility failed to protect residents from physical and verbal abuse by staff, resulting in Immediate Jeopardy due to abuse incidents by STNA 9. The facility also failed to ensure staff reported suspected abuse, allowing abuse to continue. Immediate Jeopardy was removed after corrective actions, but non-compliance remained while monitoring systemic changes.
Deficiencies (3)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse by staff, resulting in Immediate Jeopardy due to incidents involving STNA 9 hitting and verbally abusing residents R24 and R11.
F 0607: The facility failed to implement policies to prevent abuse by not ensuring staff reported allegations of physical abuse, allowing STNA 9 to continue working and abuse residents R24 and R11.
F 0812: The facility failed to ensure proper hand hygiene during meal service when STNA 7 did not wash hands with soap, dry hands with a single-use towel, or turn off faucet with a clean towel while serving supper meal trays.
Report Facts
Residents sampled: 39
Residents affected: 2
Wound size: 8
Wound size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA 9 | State Tested Nurse Aide | Named in findings for physical and verbal abuse of residents R24 and R11 |
| STNA 20 | State Tested Nurse Aide | Witnessed abuse by STNA 9 but failed to report it, contributing to continued abuse |
| STNA 8 | State Tested Nurse Aide | Witnessed abuse of R11 by STNA 9 and reported it to nurse and administration |
| STNA 10 | State Tested Nurse Aide | Witnessed restraint of R11's arm by STNA 9 and verbal abuse |
| LPN 8 | Licensed Practical Nurse | Assigned to R11's unit and involved in investigation |
| Director of Nursing | Director of Nursing | Expressed concern about failure to report abuse and staff training |
| Administrator | Administrator | Managed investigation, reported abuse to police, and stated expectations for abuse reporting |
| STNA 7 | State Tested Nurse Aide | Failed to perform proper hand hygiene during meal service |
| Staff Development LPN 2 | Licensed Practical Nurse | Monitored staff hand hygiene and reported improper practices |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 26, 2022
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to implement a comprehensive person-centered care plan and ensure adequate supervision and assistance to prevent accidents, specifically related to a fall incident involving Resident #81.
Complaint Details
The complaint investigation was substantiated. Resident #81 sustained a fall and fracture due to failure of staff to follow the care plan requiring two-person assistance for transfers. The facility also failed to maintain infection control and sanitation standards.
Findings
The facility failed to follow the care plan for Resident #81, resulting in a fall and subsequent fracture due to inadequate staff assistance during transfers. Additionally, the facility failed to maintain proper infection prevention and control practices, including hand hygiene, equipment sanitation, and food handling procedures.
Deficiencies (4)
F 0656: The facility failed to develop and implement a complete care plan meeting all resident needs, resulting in Resident #81 being transferred without required assistance, causing a fall and fracture.
F 0689: The facility failed to ensure adequate supervision and assistance to prevent accidents, leading to Resident #81's fall when transferred by one staff instead of two as required.
F 0812: The facility failed to handle kitchen equipment in a sanitary manner, as Utility Aide #1 touched clean plates with contaminated ungloved hands, risking cross contamination.
F 0880: The facility failed to establish and maintain an infection prevention and control program, including improper sanitization of glucometers, failure to perform hand hygiene after PPE removal, and inadequate cleaning of multi-use equipment.
Report Facts
Residents sampled: 26
Residents affected: 1
Date of fall incident: Apr 17, 2022
Date of x-ray diagnosis: Apr 20, 2022
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| State Registered Nurse Aide (SRNA) #14 | Attempted transfer of Resident #81 alone, resulting in fall | |
| Registered Nurse (RN) #3 | Worked on day of fall incident, did not return call | |
| Licensed Practical Nurse (LPN) #4 | Interviewed regarding care plan adherence and staff expectations | |
| State Registered Nurse Aide (SRNA) #15 | Interviewed about use of care plan as guide for resident needs | |
| Director of Nursing (DON) | Recalled fall event, confirmed staff retraining on care plan and transfers | |
| Administrator | Stated expectation for staff to follow best practices and policies | |
| Utility Aide #1 | Observed handling clean plates with contaminated hands | |
| Dietary Manager | Interviewed about hand hygiene and cross contamination risks | |
| State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #1 | Observed performing blood glucose testing with improper sanitization | |
| Staff Development Coordinator (SDC) | Provided re-education to SRNA/KMA #1 after observed errors | |
| Registered Nurse (RN) #1 | Observed not disinfecting multi-use equipment between residents |
Inspection Report
Routine
Deficiencies: 4
Date: May 16, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, food service safety, food storage, and infection prevention and control practices at the nursing home.
Findings
The facility failed to revise the Comprehensive Care Plan (CCP) after removal of a Foley catheter for one resident, served food at improper temperatures, stored food items improperly, and failed to ensure proper hand hygiene by dietary staff during food preparation and service.
Deficiencies (4)
F 0657: The facility failed to revise the Comprehensive Care Plan for Resident #91 after removal of the indwelling urinary catheter on 04/26/19, resulting in outdated care plan information.
F 0804: The facility failed to provide food and drink at safe and appetizing temperatures, with hot foods served below 135°F and cold foods above 40°F during the breakfast meal on 05/16/19.
F 0812: The facility failed to store food in accordance with professional standards, including open, undated jars of sweet pickle relish and a bottle of mayonnaise with a broken cap found in refrigerators.
F 0880: The facility failed to ensure dietary staff followed hand hygiene procedures during food preparation and service, as Dietary Aide #5 repeatedly failed to perform hand hygiene and change gloves after touching non-food surfaces.
Report Facts
Residents sampled: 23
BIMS score: 12
Food temperature: 122
Food temperature: 56
Food temperature: 85
Food temperature: 92
Food temperature: 120
Employment duration: 16
Employment duration: 5
Employment duration: 6
Employment duration: 12
Employment duration: 1
Employment duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Interviewed regarding failure to update care plan after catheter removal | |
| Licensed Practical Nurse #3 | Interviewed regarding care plan update process and failure to revise care plan | |
| Registered Nurse | Interviewed regarding responsibility to update care plans after physician orders | |
| MDS Coordinator | Interviewed regarding care plan updates and failure to revise care plan | |
| Director of Nursing | Interviewed regarding expectations for care plan revisions | |
| Administrator | Interviewed regarding expectations for timely care plan revisions and food safety | |
| Dietary Aide #4 | Observed and interviewed regarding food temperature testing | |
| Dietary Aide #2 | Observed reheating food and interviewed about food temperatures | |
| Dietary Homemaker Assistant | Interviewed regarding food delivery and temperature monitoring | |
| Executive Chef | Interviewed regarding food temperature expectations and monitoring | |
| Dietary Manager | Interviewed regarding food storage, hand hygiene, and dietary staff expectations | |
| Dietary Aide #5 | Observed and interviewed regarding failure to perform hand hygiene during food service | |
| Infection Control Nurse | Interviewed regarding importance of hand hygiene and infection prevention |
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