Inspection Reports for
Senior Star at Elmore Place

Complaint #130590-C, Complaint #130896-C, Complaint #130981-C, Incident #129966-I, Complaint #130146-C, Incident #130210-I

Regulatory insufficiencies were cited in program policies and procedures, tenant rights, and life safety. The program failed to follow established medication policies, did not respect tenant rights regarding hospice services and documentation, and failed to maintain a working alarm system on exit doors.

Investigations #130590-C, #130806-I, #130896-C, #130981-C

The program failed to maintain a working alarm system at each exit door, which allowed Tenant #1 to elope from the building unnoticed. The exit door's mag lock was malfunctioning and no alarm sounded when the door was opened.

The investigation was triggered by complaints regarding incidents #129966-I and #130210-I involving elopements of Tenant #1 and Tenant #2. Both tenants were confirmed as elopement risks and were found outside the locked memory care building without staff knowledge. No injuries were reported.

The program failed to provide adequate care and services to ensure tenant safety for two tenants with recent elopements. Both tenants exited the locked memory care building without staff knowledge, despite being identified as elopement risks and having service plans requiring safety checks.

Investigations #129966-I, #130146-C, #130210-I

The program failed to provide adequate care and services to ensure tenant safety for two tenants with recent elopements. Both tenants exited the locked memory care building without staff knowledge, despite being identified as elopement risks and having service plans requiring safety checks.

The visit was triggered by Complaint #119775-C. The complaint was substantiated as regulatory insufficiencies were found in updating service plans for tenants.

The program failed to update service plans upon significant changes for 2 of 4 discharged tenants reviewed (Tenant C2 and Tenant C3). Multiple incidents including falls, behavioral issues, and lack of updated interventions were documented but not reflected in the tenants' service plans.

The visit was triggered by complaints #116795-C and #116794-C. The investigation found the courtyard door lacked an operating alarm system, which led to Tenant #2 leaving the secured area and sustaining an injury. The complaint was substantiated by the findings.

The facility failed to ensure that all exit doors, specifically the courtyard door, had an operating alarm system as required by regulation. This deficiency contributed to an incident where Tenant #2 exited through the courtyard door, fell outside, and required emergency medical evaluation.

Type of Action: 116794-C, 116795-C

The facility failed to ensure the courtyard exit door had an operating alarm system, allowing a tenant with Alzheimer's dementia to exit unsupervised and fall outside. The door was found to have a wiring glitch and was repaired immediately.

Investigation of Incident #112363-I found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation.

The investigation of Complaint #106688-C found a regulatory insufficiency related to policy noncompliance. No regulatory insufficiencies were cited for Incident #107848-I or Complaint #106112-C.

The program failed to follow its policy on sexual relationships between residents with cognitive impairment for one tenant (Tenant #1) who had severe cognitive decline and was unable to give consent to sexual activities. The program did not complete the required Verbal Informed Sexual Consent Assessment Tool when sexual activity was suspected.

The investigation involved incidents #95540-I, #97953-I, #97252-I with no regulatory insufficiencies cited, and incidents #100797-I and #95309-I where deficiencies were found related to tenant rights and care.

The program failed to provide appropriate care and services to 1 of 2 current tenants and 1 of 4 former tenants reviewed, including failure to prevent elopement and failure to provide required assistance and gait belt use during ambulation, resulting in injury.

Incidents 95309-I and 100797-I

The program failed to provide appropriate care and services to two tenants. One tenant eloped outside in cold weather without proper staff response, and another tenant fell causing injuries due to staff not using a gait belt as required.

The investigation was triggered by Complaint #90328-C and Incident #90331-I involving Tenant #1 who was found on the floor with pain and injuries. The complaint included allegations of being pushed by another tenant. The investigation included review of incident reports, witness statements, video footage, hospital records, and interviews with staff and family. The complaint was substantiated with findings of failure to follow policies and procedures and inadequate care.

The investigation found multiple regulatory insufficiencies including failure to follow policies and procedures for incident reporting, inadequate care and treatment for tenants, and failure to report major injuries timely. Tenant #1 suffered a fall resulting in serious injuries including a brain bleed and fractures, and the incident was not reported promptly as required.

No deficiencies were cited during the onsite infection control survey completed on 2020-08-04.