Blossom Grove Alzheimer's Special Care Center

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Due to lack of supervision resident sustained a pressure ulcer while in care Due to lack of care and supervision resident sustained multiple falls while in care. Resident's medication is mismanaged by staff. Resident's personal items are not safeguarded by the facility staff.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Miller and explained the elements of the complaint. Allegation #1 - Facility staff #1 (S1), S2 and Executive Director Miller reviewed files for resident #1 (R1) and produced records from a medical facility evaluating R1 with no signs of pressure ulcers. Allegation #2 - Facility is fully staff. Executive Director Miller provided R1's resident service plan and assessed R1 as a fall risk. Facility staff are directed, and documented, for frequent checks due to fall risk. Allegation #3 - LPA obtained R1's Centrally Stored Medication chart and Physician's Order to show that R1 is receiving their medications and prescribed. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 18-AS-20220120085033

Allegation investigated: Staff improperly transferred resident resulting in resident's death.

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA met with Director, Cristina Miller, who was informed of the purpose of the visit. The investigation consisted of interviews and records review. It was alleged “Staff improperly transferred resident resulting in resident's death.” It was alleged that a resident sustained a fall at the facility when transferring into their unlocked wheelchair. It was alleged the resident broke their back and was transferred into bed by staff causing further internal injuries and the resident’s death (4) months later. The dates and times of the incident, and the name of the resident involved were not provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 6, 2025 · control 18-AS-20210216173433

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Unqualified staff administering insulin to residents.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Resident Care Coordinator Brittany Butts and explained the elements of the complaint. This investigation is based on staff interview and documentation. Regarding the allegation that unqualified staff administering insulin to residents; LPA Prieto gathered the Medication Administration Records (MAR) logs for the only two (2) residents (R1 & R2) at the facility who are insulin dependant. MAR records for each resident's have insulin are dispensed by staff that are medically qualified to do so. Staff records were obtained indicating staff who are administering insulin are documented electronically ***continued on LIC 9099C*** Unsubstantiatedthe state’s words, verbatim · CDSS document, May 6, 2024 · control 56-AS-20240501103534

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.