The Seasons at Alexandria

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's documents, policies, and procedure, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the total census of 99 residents. On [DATE], the Local Health Department (LHD) informed the facility that Resident (R) 121 had been diagnosed with Legionnaire's disease while in the hospital. Testing conducted by a third-party water specialist revealed positive areas for legionella in the facility. On [DATE] uncontrolled levels of growth were identified in the hot shower of room [ROOM NUMBER] and in the cooling tower. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for five of five sampled residents, Resident (R) 4, R37, R38, R40, and R41. R4, who was left unsupervised outside in 90-degree weather for 30 to 45 minutes on 08/04/2024 required a transfer to the Emergency Department (ED) for evaluation of mental status changes and a temperature of 105 degrees Fahrenheit (F) and as of 08/07/2024, the resident had not yet returned to the facility. Review of R4's Comprehensive Care Plan (CCP) revealed no care plan interventions in place for supervision while he was outside. [...]

Inspectors wroteBased on observation, interview, record review, review of the website localconditions.com, review of the website my.clevelandclinic.org, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five sampled residents, Resident (R) 4. On 08/04/2024, R4 was assisted outside in his wheelchair by State Trained Nurse Assistant (STNA) 40 and was left unattended in 90 degree Fahrenheit (F) weather for 30 to 45 minutes. R4 required transfer to the Emergency Department (ED) for evaluation of mental status changes, a temperature of 105 degrees F, and as of 08/07/2024, the resident had not yet returned to the facility. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to protect two (2) of thirty-nine (39) sampled residents (R) from physical and verbal abuse by staff (R24 and R11). During the first week of May 2024 (exact date unknown), State Tested Nurse Aide (STNA) 20 witnessed STNA 9 providing care to R24, and observed STNA 9 being rough while providing care to the resident. However, STNA 20 failed to report the incident of possible physical abuse by STNA 9 towards R24 to administrative staff. Therefore, STNA 9 continued to work, and on 05/19/2024, STNA 9 held R11's wrist and hit the resident repeatedly with her fist in the left upper arm. STNA 8 heard STNA 9 state to R11, I told you not to hit me. I hit harder than you and you don't hit women. The incident resulted in R11 sustaining a large bruise to the left upper arm. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure its staff implemented the facility's abuse policy regarding reporting allegations of physical abuse for one of 39 sampled residents, (R) 24. State Tested Nurse Aide (STNA) 20, during the first week of May 2024 (exact date unknown), observed STNA 9 being rough when providing care for R24. Review of the facility's abuse policy dated 11/01/2023, revealed employees must always report abuse or suspicion of abuse immediately to the Administrator or designee. STNA 20 failed to report the allegation of abuse to the Administrator or designee, and STNA 9 continued to work providing care to facility residents. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review, review of the facility's nursing assistant (State Registered Nurse Assistant/SRNA) job description and review of the facility's policy, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-six (26) sampled residents (Resident #81). The facility's assessed and care planned Resident #81 to require the extensive assistance of two (2) staff for transfers and bed mobility. However, on 04/17/2022, State Registered Nurse Aide (SRNA) #14 attempted to transfer Resident #81 from a chair to the bed, without assistance from another staff member. The transfer was unsuccessful, resulting in a fall. Three (3) days later, Resident #81 complained of severe pain and underwent imaging three to the right ankle that resulted in a diagnosis of a nondisplaced intra-articular fracture of the medial tibia.

Inspectors wroteBased on interview, record review, review of the facility's investigative report, review of the facility's job description, and review of the facility's policies, it was determined the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (1) of twenty-six (26) sampled residents (Resident #81). According to Resident #81's Comprehensive Assessment, two (2) or more staff members were required to assist the resident for transfers and bed mobility. However, on 04/17/2022, Resident #81 sustained a fall when one (1) staff member, State Registered Nurse Aide (SRNA) #14 transferred the resident from a chair to the bed, with no assistance. Three (3) days later, Resident #81 complained of severe pain and underwent imaging to the right ankle that resulted in a diagnosis of a nondisplaced intra-articular fracture of the medial tibia.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.