HERITAGE HAUS

A revisit survey was completed on 5/14/24 for all previous deficiencies cited on 12/21/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 5/14/24 for all previous deficiencies cited on 12/21/23. 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 12/21/23. A deficiency was cited.

Based on observation, and interviews, 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 one sample participant (resident) (#2). Findings include:Chapter VII regulations governing assisted living residences, part 14.7, requires the residence to ensure that each resident receives proper administration and /or monitoring of medications. Chapter VII regulations governing assisted living residences, part 2.27, defines "medication monitoring" as (C) Visual observation of the resident to ensure compliance. The residence's undated Medication Administration Policy, read in part: "QMAP (qualified medication administration person) must stay with the resident while the resident is taking medication ... it is the QMAP's responsibility to witness each resident taking medication ... " On 12/21/23 at approximately 8:00 a.m., Staff #4 dispensed Resident #2's medication. Staff #4 handed Resident #2 his medication patch; however, Resident #2 walked away once given and Staff #4 began to dispense another resident's medications without observing Resident #2 apply his medication patch, as required. On 12/21/23 at 11:20 a.m., Staff #4 stated that the residence's QMAPs gave Resident #2 his medication patch daily and did not visually observe the administration of the medication because Resident #2 preferred to apply the patch himself. Staff #4 confirmed that each QMAP administered Resident #4's medication patch on a daily basis and did not visually observe the administration of the patch. On 11/20/23 at 11:25 a.m., the administrator stated she was aware that Resident #2 preferred to self-apply his medicated patch. She stated that the residence staff administered Resident #2's medicated patch to him and then he self-applied, privately. She confirmed that the QMAPs did not visually observe Resident #2 self-apply his medicated patch, as required.

A relicensure survey was completed on 12/21/23. A deficiency was cited.

Based on observation, record review and interviews, the residence failed to ensure that each resident received proper administration and/or monitoring of medications, affecting one sample resident (#2) who staff had a pattern of not observing medication administration. Findings include:Chapter VII regulations governing assisted living residences, part 2.27, defines "Medication Monitoring" as: (C) Visual observation of the resident to ensure compliance. The residence's undated Medication Administration Policy, read in part: "QMAP (qualified medication administration person) must stay with the resident while the resident is taking medication ... it is the QMAP's responsibility to witness each resident taking medication ... "On 12/21/23 at approximately 8:00 a.m., Staff #4 dispensed Resident #2's medications. Staff #4 handed Resident #2 his medicated patch; however, Resident #2 walked away once he was given the patch and Staff #4 began to dispense another resident's medications without observing Resident #2 apply his medicated patch, as required. On 12/21/23 at 11:20 a.m., Staff #4 stated that the residence's QMAPs gave Resident #2 his medication patch daily and did not visually observe the administration of the medication because Resident #2 preferred to apply the patch himself. Staff #4 confirmed that each QMAP administered Resident #4's medication patch on a daily basis and did not visually observe the administration of the patch. On 11/20/23 at 11:25 a.m., the administrator stated she was aware that Resident #2 preferred to self-apply his medicated patch. She stated that the residence staff administered Resident #2's medicated patch to him and then he self-applied, privately. She confirmed that the QMAPs did not visually observe Resident #2 self-apply his medicated patch, as required.

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 7.6.6 An administrator training program shall meet all of the following requirements:(B) The curriculum includes at least 40 actual hours, 20 of which shall focus on applicable state regulations. The remaining 20 hours shall provide an overview of the following topics:(1) Business operations including, but not limited to:(a) Budgeting,(b) Business plan/service model,(c) Insurance,(d) Labor laws,(e) Marketing, messaging and liability consequences, and(f) Resident agreement.(2) Daily business management including, but not limited to,(a) Coordination with external service providers (i.e., community and support services including case management, referral agencies, mental health resources, ombudsmen, adult protective services, hospice, and home care),(b) Ethics, and(c) Grievance and complaint process.(3) Physical plant(4) Resident care including, but not limited to:(a) Admission and discharge criteria,(b) Behavior expression management,(c) Care needs assessment,(d) Fall management,(e) Nutrition,(f) Person-centered care,(g) Personal versus skilled care,(h) Quality management education,(i) Resident rights,(j) Sexuality and aging,(k) Secure environment, and(l) Medication Management.(5) Resident psychosocial needs including, but not limited to,(a) Cultural competency (ethnicity, race, sexual orientation),(b) Family involvement and dynamics,(c) Mental health care (maintaining good mental health and recognizing symptoms of poor mental health),(d) Palliative care standards, and(e) Resident engagement.