6 Reports
Inspection Report — Aug 1, 2025
Complaint Investigation State
Date: Aug 1, 2025
Visit Reason
The inspection was conducted following a complaint regarding a medication administration error involving Resident #1 on 7/23/2025.
Complaint Details
The complaint involved a medication administration error where Resident #1 was mistakenly given Resident #2's medications on 7/23/2025, leading to hypotension, acute drug overdose, altered mental status, arrhythmia, bradycardia, and dementia. The error was substantiated based on incident and medication error reports and hospital discharge summary.
Findings
The facility failed to use safe and appropriate procedures when administering medications, resulting in Resident #1 being mistakenly given Resident #2's medications, causing illness and hospitalization.
Deficiencies (1)
Failure to use safe and acceptable procedures for medication administration, resulting in Resident #1 receiving incorrect medications.
Report Facts
Medication Dosages: 8
Dates: Jul 23, 2025
Dates: Aug 1, 2025
Inspection Report — Aug 1, 2025
Plan of Correction State
Date: Aug 1, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Bolster Heights Residential Care, addressing noncompliance with medication administration procedures following a medication error involving Resident #1.
Findings
The facility failed to use safe and appropriate procedures when administering medications, resulting in Resident #1 mistakenly receiving Resident #2's medications, leading to illness and hospitalization. The error was confirmed by review of records and hospital discharge summary.
Deficiencies (1)
Residents shall receive only the medications ordered by their authorized licensed practitioner in the correct dose, time, and route; this was not met as Resident #1 was given Resident #2's medications.
Report Facts
Medication error date: Jul 23, 2025
Plan of correction completion date: Aug 14, 2025
Reeducation deadline: Sep 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Merissa Poland | Administrator | Named as administrator of the facility on the report |
| Director of Nursing | Responsible for implementation of corrective actions |
Inspection Report — Sep 24, 2024
State
Date: Sep 24, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Bolster Heights Residential Care, related to regulatory licensing and certification oversight of an assisted housing facility.
Findings
Bolster Heights Residential Care is in substantial compliance with the regulations governing the licensing and functioning of Level IV PNMI Residential Care Facilities, with no deficiencies noted in the report.
Inspection Report — Aug 14, 2024
Complaint Investigation State
Date: Aug 14, 2024
Visit Reason
The inspection was conducted as part of case investigations numbered 2024-AHP-38149, 38153, and 38273 for the Bolster Heights Residential Care facility.
Complaint Details
The visit was related to complaint investigations as indicated by the case investigation numbers; however, the facility was found to be in substantial compliance.
Findings
Bolster Heights Residential Care, a PNMI Level IV Residential Care Facility, is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV, PNMI Residential Care Facilities and Infection Prevention and Control.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Merissa Poland | Administrator | Named as the facility administrator in the report header. |
Inspection Report — Jun 10, 2024
State
Date: Jun 10, 2024
Visit Reason
This document is a statement of deficiencies and plan of correction for Bolster Heights Residential Care, a PNMI Level IV Residential Care Facility, related to a case investigation.
Findings
Bolster Heights Residential Care is in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV, PNMI Residential Care Facilities and Infection Prevention and Control.
Inspection Report — Mar 22, 2023
Re-Inspection State
Date: Mar 22, 2023
Visit Reason
The visit was a re-inspection to verify correction of previously cited deficiencies related to medication management, expired medications, service plan updates, sanitation, and physical plant requirements at Bolster Heights Residential Care.
Findings
The inspection found multiple deficiencies including lack of evidence of annual diabetes training for staff, improper handling of expired medications, incomplete service plans, sanitation issues with refrigerator racks, and physical plant maintenance needs such as worn refrigerator racks and damaged bathroom surfaces. Plans of correction were documented with completion dates in April 2023.
Deficiencies (8)
Unlicensed assistive personnel were not trained by a registered professional nurse in diabetes management as required.
Expired and discontinued medications were not properly removed or destroyed.
Service plans did not reflect changes of care and were not updated timely.
Medication records and storage were not properly maintained or authorized.
Refrigerator racks were worn and rusting, creating difficult to clean surfaces.
Facility failed to ensure shelving in refrigerator was in good condition with cleanable surfaces.
Bathroom surfaces had chipped paint and damage creating an uncleanable surface.
Various physical plant deficiencies including missing covers, replaced handrails, and repaired walls were noted and corrected.
Report Facts
Deficiencies cited: 8
Plan of Correction Completion Dates: 6
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