Flourish Supportive Living at Owens

A revisit survey was completed on 2/10/25 for all previous deficiencies cited on 10/15/24. 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 10/15/24. A deficiency was cited. Based on observation, interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting three of three sample participants (residents) (#1-#3).Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires the residence to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.A. Resident #3 was admitted to the residence on 4/27/23.EnuloseA written practitioner' s order, dated 8/21/24, directed the residence to administer Enulose 30 mL twice daily. However, the September and October 2024 electronic medication administration record (eMARs) read the residence failed to administer the medication on 9/9 and 10/15 in the morning, 9/8 and 10/8 in the evening, and two doses on 9/19, 9/30, 10/9-10/12 and 10/14/24, for a total of nineteen missed doses.Levocarnitine A written practitioner' s order, dated 4/3/24, directed the residence to administer the levocarnitine 330 mg once daily at noon. However, the October 2024 eMAR revealed that the residence failed to administer the medication on 10/1/24, for a total of one missed dose. B. Evidence obtained during the on site visit revealed the residence additionally failed to comply with authorized practitioner' s orders for Residents #1 and #2.C. InterviewsOn 10/15/24 at 3:13 p.m., the administrator designee stated the administrator and house manager were responsible for ordering medications from the pharmacy. The administrator designee stated she was unaware why the residence was out of stock for medications for Residents #1-#3.On 10/15/24 at approximately 3:22 p.m., the administrator acknowledged she expected the residence to be responsible for complying with practitioner' s orders. The administrator stated the house manager was supposed to order medication ..

A relicensure survey was completed on 10/15/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure personnel files for current employees were onsite and readily available for department review, affecting three of three sample staff (#1-#3). Findings include:Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide resident care services.On 10/15/24 at 10:20 a.m., the personnel files for Staff #1-#3 were requested.On 10/15/24 at 12:46 p.m., the personnel files for Staff #1-#3 were again requested.On 10/15/24 at 2:40 p.m., the personnel files for Staff #1-#3 were request.. Based on observations and interviews, the residence failed to store refrigerated medications in a refrigerator that was not accessible to the residents, affecting seven current residents.Findings include:Throughout the onsite visit on 10/15/24 from 8:50 a.m. to 4:30 p.m., the medication refrigerator located between the kitchen and hallway of the residence was unlocked and accessible to residents. The refrigerator contained the following:Six injectable pens of Lantus insulin 100 units for Resident #2Three Humulin 70/30 insulin injectable pens for Resident #2Three 2 mg Ozempic injectable pens for Resident #1One glucagon 1 mg injection for Resident #2.When Staff #3 was away passing.. Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#1-#3).Findings include:1. Resident #3 was admitted to the residence on 4/27/23.a. EnuloseA written practitioner' s order, dated 8/21/24, directed the residence to administer Enulose 30 mL twice daily. However, the September and October 2024 electronic medication administration record (eMARs) read the residence failed to administer the medication on 9/9 and 10/15 in the morning, 9/8 and 10/8 in the evening, and two doses on 9/19, 9/30, 10/9-10/12 and 10/14/24, for a total of ninetee.. Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting seven current residents.Findings include:On 10/15/24 at 9:19 a.m., controlled medication count sheets for October 2024, quarterly medication audits and cardiopulmonary resuscitation (CPR) and first aid certifications for staff members to correspond with the September and October 2024 staff schedules were requested, but were not provided upon request. On 10/15/24 at 10:20 a.m., personnel files for Staff #1-#3 and signed practitioner orders to correspond with the September and October 2024 electronic medication administration records.. 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 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration o..

A revisit survey was completed on 2/13/24 for all previous deficiencies cited on 10/11/22. No deficiencies 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