Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
May 14, 2025
Visit Reason
The inspection was conducted related to the investigation of Incident #127621-I and Complaint #128563-C regarding the facility's failure to develop service plans that reflected outside service providers.
Findings
The facility failed to update service plans to accurately reflect outside service providers such as physical therapy, occupational therapy, speech therapy, palliative care, and home health care for multiple tenants. Service plans were not updated to reflect therapy discharges or ongoing outside services.
Complaint Details
The visit was complaint-related, investigating Incident #127621-I and Complaint #128563-C. The complaint was substantiated by findings that service plans did not reflect outside service providers for 2 of 3 current tenants and 1 of 2 discharged tenants reviewed.
Deficiencies (1)
| Description |
|---|
| Failed to develop service plans that reflected outside service providers including hospice care, home health care, occupational therapy, and physical therapy for tenants. |
Report Facts
Number of tenants without cognitive impairment: 27
Number of tenants with cognitive impairment: 3
Total census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed tenants' service plans and therapy discharges | |
| Chief Nursing Officer and Owner | Interviewed regarding Tenant C1's palliative care services | |
| Executive Director | Interviewed about Tenant C1's therapy services upon admission |
Inspection Report
Recertification
Census: 29
Deficiencies: 3
Sep 25, 2024
Visit Reason
The inspection was conducted as a recertification visit combined with an investigation of Incident #121801-I to determine compliance with certification of an Assisted Living Program.
Findings
The inspection identified regulatory deficiencies including failure to follow the door alarm policy resulting in an elopement incident, improper medication administration with incorrect dosage given to a tenant, and failure to complete background checks prior to employment for one staff member.
Complaint Details
The visit included an investigation of Incident #121801-I related to a tenant elopement event.
Deficiencies (3)
| Description |
|---|
| Staff failed to follow the program's Door Alarm Policy regarding a tenant who eloped. |
| Program staff failed to properly administer medications as prescribed by the tenant's physician, resulting in incorrect dosage administration for one tenant. |
| Program failed to complete background checks prior to hire for one employee. |
Report Facts
Census: 29
Tenants without cognitive impairment: 28
Tenants with cognitive impairment: 1
Medication dosage discrepancy duration: 14
Staff background check delay: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Admitted clearing door alarm without visual check; received disciplinary action | |
| Staff B | Administered incorrect medication dosage; background check completed late | |
| Executive Director | Confirmed findings related to medication error and background check delay |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Feb 16, 2023
Visit Reason
The inspection was conducted to investigate Complaint #110172-C regarding regulatory insufficiencies at Boyson Heights Senior Living Community.
Findings
The program failed to develop individualized service plans reflecting tenants' identified needs, specifically for two tenants. Tenant #1's medication refusals were not documented in the service plan, and Tenant #2's significant weight loss and related interventions were not reflected in the service plan.
Complaint Details
Complaint #110172-C was investigated and found regulatory insufficiency related to individualized service plans for tenants.
Deficiencies (1)
| Description |
|---|
| Failure to develop service plans that reflected the identified needs of tenants, including medication refusals and weight loss interventions. |
Report Facts
Number of tenants without cognitive impairment: 44
Number of tenants with cognitive impairment: 2
Total census: 46
Medication refusals: 7
Weight loss (pounds): 20.6
Weight loss (pounds): 10.2
Tenant #2 weight: 96.6
Inspection Report
Original Licensing
Census: 19
Deficiencies: 5
Aug 10, 2021
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification for an Assisted Living Program.
Findings
The inspection identified multiple regulatory insufficiencies including failure to document treatments on the treatment administration record, incomplete nurse delegation documentation within required timeframes, failure to complete required criminal history and abuse background checks prior to employment, failure to complete tenant evaluations after significant changes, and failure to develop service plans based on evaluations reflecting tenant needs.
Deficiencies (5)
| Description |
|---|
| Failed to document treatments on the treatment administration record (TAR) as indicated in the Program's Medication Management Policy for 2 of 3 tenants reviewed. |
| Failed to have the newly hired registered nurse document a review to ensure staff were sufficiently trained in all tasks within 60 days of employment for 2 of 3 staff reviewed. |
| Failed to request criminal history and abuse record checks prior to employment for 2 of 5 staff reviewed. |
| Failed to complete evaluations within 30 days of occupancy or after significant change for 1 of 1 tenant reviewed who was hospitalized. |
| Failed to develop service plans based on evaluations and failed to develop service plans that reflected the service needs of tenants for 3 of 3 tenants reviewed. |
Report Facts
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 1
Total census: 19
Staff hire date: Apr 28, 2021
Staff hire date: Feb 16, 2021
Staff hire date: Nov 17, 2020
Staff hire date: Feb 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff reviewed for nurse delegation and medication administration; failed to have nurse delegation training on catheter care. | |
| Staff B | Staff reviewed for background checks; failed to have child and dependent adult abuse registry checks prior to employment. | |
| Staff C | Staff reviewed for nurse delegation and background checks; nurse delegation was delayed beyond 60 days and background checks incomplete prior to employment. | |
| Director of Nursing | Director of Nursing | Delegating nurse responsible for nurse delegation procedures and confirmed deficiencies in documentation and delegation. |
| Executive Director | Executive Director | Confirmed background checks were completed after management change. |
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