Blossom View Assisted Living

A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 3/22/23. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey was completed on 3/22/23. Deficiencies were cited. Based on observation and interview, the facility failed to maintain a home-like quality feel to participants during medication administration, affecting five participants (#4, #6-#7, #11-#12). Findings include: 1. Observation On 3/21/23 at approximately 8:00 a.m., medication administration had taken place in the kitchen/dining room. Participants #4, #6, #7, #11, and #12 were seated at the dining table, and were then called up one by one to the kitchen counter for their medications. 2. InterviewOn 3/21/23 at approximately 1:24 p.m. the administrator stated staff always called up the participants for their medications, especially during the breakfast pass because it was easiest. She said, "It was not necessarily home-like I guess." The administrator stated staff asked participants where they wanted to receive their medications and all said they wanted them in the kitchen. She stated that was something the facility had always done. Based on observation, interview, and record review, the facility (residence) failed to observe participant' s (resident' s) right to privacy affecting six participants (#7, #13, #14, #15, #17, #18).Findings include: 1. Residence Policy The residence' s Resident Rights policy, dated 12/5/19, read in part: "The right to privacy."2. Observation On 3/22/23 an environmental tour of the residence revealed the following residents shared a room, though none of the rooms had any provision for privacy: Resident #7 and #13Resident #14 and #15Resident #17 and #18 3. Interviews On 3/21/23 at approximately 10:20 a.m., Resident #14 stated he wished he had more privacy in the room he shared with Resident #15. He stated he would liked to have had a privacy curtain or some type of divider. Resident #14 stated there was a private room that had opened up recently and had asked the administrator to be transferred. He added he had been placed on the waiting list for the private room, but had not heard back yet on if he had been approved. On 3/22/23 .. Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting 15 current participants (residents). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.31, requires that the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review.The residence' s Medication Administration policy, dated 1/11/19, read in part: "All medication documentation will be reviewed by the supervisor/administrator ..."On 3/22/23 at approximately 7:30 a.m., the residence' s q..

A relicensure survey was completed on 3/22/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of three sample staff (#5) who provided direct care to at-risk residents, affecting 15 current residents.Findings include:1. Referencesa. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, "... individuals receiving care and services from persons employed in programs .. Based on observation and interview, the residence failed to ensure designated smoking areas and resident rooms occupied by smokers had fire resistant wastebaskets, affecting nine residents (#1, #3, #4, #12-#15, #17, #18).Findings include: An environmental tour of the rooms for Residents #1, #3, #4, #12-#15, #17, and #18 revealed the rooms did not contain fire resistant wastebaskets as required by regulationOn 3/22/23 at approximately 1:24 p.m., the adminis.. Based on observation, interview and record review revealed the residence failed to ensure house rules listed all possible actions which may be taken by the assisted living resident if any rule is knowingly violated by a resident and ensure the house rules addressed consumption of alcohol, affecting 15 current residents.Findings include:1. Residence policyThe residence' s House Rules policy, dated 3/4/20, read in part, residents were not allowed use of controlled su.. Based on observation, interview, and record review, the residence failed to observe resident' s right to privacy affecting six residents (#7, #13, #14, #15, #17 and #18)).Findings include: 1. Residence Policy The residence' s Resident Rights policy, dated 12/5/19, read in part: "The right to privacy."2. Observation On 3/22/23 an environmental tour of the residence revealed the following residents shared a room, though none of the rooms had any provision for privac.. Based on observation, record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location along with the full contact information for the Colorado Department of Public Health and Environment, affecting 15 current residents.Findings include:1. Residence policyThe residence' s Resident Grievance Policy, dated 12/5/19, read in part, the residents could contact .. Based on record review and interview, the residence failed to ensure the administrator and qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration records, controlled substances list, medication error reports, and medication disposal records, quarterly, affecting 15 current residents. Findings include: The residence' s Medication Administration policy, dated 1/11/19, read in part: "A.. Based on record review and interview, the residence failed to have a quality management program (QMP) that improved client safety and well-being, affecting 15 current residents.Findings include:On 3/22/23 at 7:20 a.m., the residence' s QMP was requested.On 3/22/23 at approximately 9:00 a.m., the administrator provided a QMP binder that included a QMP policy, dated 9/3/15, that read in part, the residence would maintain a QMP.On 3/22/23 at 1:24 p.m.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.6.8 The administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (J) Complying with all applicable federal, state, and local laws concer..