Inspection Reports for Senior Star at Elmore Place
4502 Elmore Avenue, Davenport, IA 52807, United States, IA, 52807
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 9, 2025, identified deficiencies related to tenant safety after two tenants eloped from the locked memory care building without staff knowledge. Earlier inspections showed a pattern of similar issues including failures to update service plans, inadequate door alarms, and insufficient staffing to prevent elopements and ensure tenant safety. Deficiencies frequently involved tenant safety, care planning, and staffing, with several substantiated complaints related to elopements, falls, and policy noncompliance. Enforcement actions included civil penalties ranging from $500 to $5,000 in prior years, but no license suspensions or immediate jeopardy findings were listed in the available reports. The facility’s inspection history shows ongoing challenges with safety and care documentation, with recent inspections continuing to cite related deficiencies.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
4.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% better than Iowa average
Iowa average: 4.4 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
38 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Sep 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to incidents of elopement involving two tenants at the Senior Star at Elmore Place Memory Care facility.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to provide adequate care and services to ensure tenant safety for two tenants with recent elopements. |
Report Facts
Total census: 38
Tenant #1 age: 70
Tenant #1 GDS score: 5
Tenant #2 age: 73
Tenant #2 GDS score: 4
Distance between MC and ALP buildings: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Assistant Executive Director | Author of the Plan of Correction submitted in response to the investigation. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jun 12, 2024
Visit Reason
The inspection was conducted as part of an investigation into Complaint #119775-C regarding regulatory insufficiencies in service plans at Senior Star at Elmore Place Memory Care.
Findings
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.
Complaint Details
The visit was triggered by Complaint #119775-C. The complaint was substantiated as regulatory insufficiencies were found in updating service plans for tenants.
Deficiencies (1)
| Description |
|---|
| Failure to update service plans upon significant change for tenants with documented falls and behavioral issues. |
Report Facts
Number of tenants without cognitive impairment: 4
Number of tenants with cognitive impairment: 36
Total census: 40
Number of falls for Tenant C2 in January 2024: 3
Number of unwitnessed falls for Tenant C3: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Assistant Executive Director | Named in Plan of Correction and confirmed tenants' service plans were not updated |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Nov 15, 2023
Visit Reason
The inspection was conducted as part of the investigation of Complaint #116795-C and Complaint #116794-C regarding regulatory insufficiencies related to life safety and emergency policies in a dementia-specific assisted living program.
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all exit doors had an operating alarm system in a dementia-specific program, affecting Tenant #2 who exited through an unlocked courtyard door and fell. |
Report Facts
Number of tenants without cognitive impairment: 4
Number of tenants with cognitive impairment: 34
Total census: 38
Global Deterioration Scale score: 6
Incident date: Nov 8, 2023
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Sep 20, 2023
Visit Reason
Investigation of Incident #112363-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #112363-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 3
Number of tenants with cognitive impairment: 35
Total census: 38
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Jan 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #106688-C regarding the program's failure to follow its Sexual Relationships Between Residents with Cognitive Impairment policy.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to follow the Sexual Relationships Between Residents with Cognitive Impairment policy for Tenant #1. |
Report Facts
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 27
Total census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Assistant Executive Director | Named as the author of the Plan of Correction in response to Complaint #106688-C. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Dec 9, 2021
Visit Reason
The inspection was conducted as an investigation of complaints/incidents related to tenant care and safety at Senior Star at Elmore Place Memory Care.
Findings
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.
Complaint Details
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.
Deficiencies (1)
| Description |
|---|
| Failure to provide appropriate care and services to tenants, including inadequate response to elopement and failure to use gait belt during ambulation causing injury. |
Report Facts
Total census: 34
Tenants without cognitive disorder: 6
Tenants with cognitive disorder: 28
Duration outdoors: 12
Outdoor temperature: 32
Incident date: Jan 26, 2021
Incident date: Nov 25, 2021
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Dec 2, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to allegations and incidents involving tenant safety and care at Senior Star at Elmore Place Memory Care.
Findings
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.
Complaint Details
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.
Deficiencies (4)
| Description |
|---|
| Program failed to follow its policy and procedure regarding the completion of incident reports and critical incidents regarding 1 of 3 tenants. |
| Program failed to provide services, care and treatment that were adequate and appropriate for 1 of 3 tenants reviewed (Tenant #1). |
| Program failed to ensure major injuries were reported to the Department as required for 1 of 3 tenants reviewed (Tenant #1). |
| Program notification to the department was not made within required timeframe for incidents causing major injury. |
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 33
Total census: 35
Date survey completed: Dec 2, 2020
Inspection Report
Routine
Census: 35
Deficiencies: 0
Aug 4, 2020
Visit Reason
The inspection was conducted as an onsite infection control survey for an Assisted Living Program for People with Dementia.
Findings
No deficiencies were cited during the onsite infection control survey completed on 2020-08-04.
Report Facts
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 35
Total census: 35
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Sep 26, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to Incident #85523-I involving a tenant found deceased with positional asphyxia and concerns about the use of bedside positioning bars.
Findings
The investigation found regulatory insufficiencies in program policies and procedures, tenant rights, service plans, and structural requirements related to the safe use and placement of bedside positioning bars. The tenant's death was linked to improper use of a U bar without a physician's order and inadequate staff training and monitoring.
Complaint Details
The complaint investigation was triggered by Incident #85523-I where Tenant #1 was found deceased with her neck resting on a U bar attached to her bed. The autopsy revealed death from positional asphyxia. The investigation revealed failures in policy adherence, staff training, and proper use of positioning bars without physician orders.
Deficiencies (5)
| Description |
|---|
| Program failed to follow policy regarding bedside positioning bars for 6 of 6 tenants who utilized positioning bars. |
| Program failed to provide care, treatment and services that were adequate and appropriate for Tenant #1. |
| Program failed to maintain a building that was safe regarding the placement and installation of assistive bed positioning bars for Tenant #1. |
| Program failed to develop a service plan that reflected the identified needs of Tenant #1. |
| Program policies and procedures, including those for incident reports, were not followed regarding bedside positioning bars and reporting incidents. |
Report Facts
Number of tenants with cognitive disorder: 39
Number of tenants without cognitive disorder: 0
Number of tenants using U bars: 5
Number of tenants using bedside positioning bars: 6
Tenant #1 weight: 97.8
Tenant #1 weight: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Health Service Administrator | Author of Plan of Correction |
| Nurse #1 | Previously Director of Nursing, involved in incident and interviews regarding Tenant #1 and U bar placement | |
| Nurse #2 | Director of Nursing (DON) | DON at time of incident, confirmed no physician order for U bar, involved in interviews |
| Staff B | Nurse Manager | Placed U bar on Tenant #1's bed, involved in interviews |
| Staff A | Incident witness who found Tenant #1 on floor with neck on U bar | |
| Director of Corporate Operations | Provided information about corporate policies and levels of care | |
| Health Services Administrator | Interim DON | Revealed policy awareness and actions taken after incident |
| Executive Director | Alerted to incident and observed Tenant #1's apartment | |
| Staff C | Provided information about Tenant #1's scheduled checks | |
| Staff D | Did not observe bed rail on Tenant #1's bed | |
| Staff E | Responded to Tenant #1's apartment, unfamiliar with tenant and U bar | |
| Staff F | Provided information about bed making and U bar placement | |
| Staff G | Revealed Tenant #1 was total assist with ADLs and on toileting schedule | |
| Staff H | Observed Tenant #1's apartment door closed at night | |
| Staff I | Maintenance | Reported work orders and installation of bed rails |
| Staff J | Maintenance | Reported storage of beds and installation of Halo bars |
Inspection Report
Monitoring
Census: 40
Deficiencies: 1
May 8, 2019
Visit Reason
The visit was an on-site monitoring inspection by the Department of Inspections and Appeals to investigate regulatory insufficiency related to tenant rights and care services at Senior Star at Elmore Place.
Findings
The program failed to provide appropriate services to 5 tenants as evidenced by incomplete or missing documentation of safety checks and service plan details. Specific deficiencies included lack of documentation on frequency and performance of safety checks for tenants with cognitive disorders.
Deficiencies (1)
| Description |
|---|
| Failure to provide appropriate services and adequate care as required by tenant rights regulations, including incomplete safety check documentation for tenants with cognitive disorders. |
Report Facts
Number of tenants with cognitive disorder: 40
Number of tenants without cognitive disorder: 0
Total census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Health Service Administrator | Author of Plan of Correction response to the inspection |
| Stephanie Dodge | DIA monitor | Conducted the on-site monitoring visit |
Inspection Report
Renewal
Census: 38
Deficiencies: 0
Mar 28, 2019
Visit Reason
Recertification visit to determine compliance with licensing rules for an Assisted Living Program for Persons with Dementia (ALP-D) and investigation into Incident #82218-I.
Findings
No regulatory insufficiencies were cited during the recertification visit or the investigation into the incident.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Feb 21, 2019
Visit Reason
Investigation of Complaint #81092-C and Incident #81155-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint and incident.
Complaint Details
Investigation of Complaint #81092-C and Incident #81155-I found no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 40
Number of tenants without cognitive disorder: 0
Total Census: 40
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Jan 31, 2018
Visit Reason
Investigation into Complaint #73448-C regarding the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation into Complaint #73448-C found no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 40
Number of tenants without cognitive disorder: 0
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 0
Dec 18, 2017
Visit Reason
Investigation of Incident #71122-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation of Incident #71122-I.
Complaint Details
Investigation of Incident #71122-I with no regulatory insufficiencies cited.
Report Facts
Number of tenants with cognitive disorder: 41
Number of tenants without cognitive disorder: 0
Total Population of Program at time of on-site: 41
TOTAL census of Assisted Living Program: 41
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Jun 1, 2017
Visit Reason
Investigation of Incident #67951 at the assisted living program.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #67951; no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 32
Total population of Program at time of on-site: 34
Total census of Assisted Living Program: 34
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Mar 2, 2017
Visit Reason
Investigation of Complaint #64690-C at the assisted living facility Senior Star at Elmore Place.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #64690-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 36
Number of tenants without cognitive disorder: 0
Total population at time of on-site: 36
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Mar 2, 2017
Visit Reason
Investigation of Complaint #64690-C at the assisted living facility Senior Star at Elmore Place.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Complaint Details
Complaint #64690-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 36
Number of tenants without cognitive disorder: 0
Total population of Program at time of on-site: 36
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Feb 29, 2016
Visit Reason
Investigation of Complaint #57972 regarding the Assisted Living Program at Senior Star at Elmore Place.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint. The census at the time was 36 residents, all with cognitive disorder.
Complaint Details
Complaint #57972 was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants with cognitive disorder: 36
Total population of program at time of on-site: 36
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Aug 31, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation related to staffing concerns at Senior Star at Elmore Place, Davenport, IA.
Findings
The investigation found the allegation of staffing to be unsubstantiated with no regulatory insufficiencies identified. The program staff responded appropriately and immediately to the self-reported incident.
Complaint Details
The complaint involved staffing allegations which were investigated and found to be unsubstantiated based on review of tenant file, incident report, staff interviews, nurse interview, and policy review.
Report Facts
Total census of Assisted Living Program: 36
Number of tenants with cognitive disorder: 36
Number of tenants without cognitive disorder: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Director | Facility Director addressed in the report |
| Rose Boccella | Program Coordinator | Author of the report and contact person |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Apr 22, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to admission/discharge and staffing at Senior Star at Elmore Place.
Findings
The investigation found all allegations to be unsubstantiated with no regulatory insufficiencies identified. Tenant files, incident reports, staff interviews, and policies were reviewed, confirming adequate staffing and fall prevention interventions.
Complaint Details
Allegations of admission/discharge issues and staffing concerns were investigated and found unsubstantiated.
Report Facts
Number of tenants with cognitive disorder: 36
Number of tenants without cognitive disorder: 0
Total census of Assisted Living Program: 36
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Feb 18, 2015
Visit Reason
The inspection was conducted as a Final Recertification and Complaint/Incident Investigation to determine compliance for an Assisted Living Program, triggered by regulatory insufficiencies related to Tenant Rights and Staffing.
Findings
The report found regulatory insufficiencies in Staffing and Tenant Rights, including failure to have sufficient trained staff available at all times and incidents involving tenant elopement without staff knowledge. A $500 civil penalty was assessed due to repeated staffing deficiencies.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in Staffing and Tenant Rights, including an incident where Tenant #1 left the facility without staff knowledge and was redirected back by carolers. The tenant had severe cognitive decline and the program failed to follow proper procedures to prevent elopement.
Deficiencies (1)
| Description |
|---|
| Failure to have a sufficient number of trained staff available at all times to meet tenants' identified needs, evidenced by tenant elopement without staff knowledge. |
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Director | Named as Director of Senior Star at Elmore Place Memory Care |
| Rose Boccella | Program Coordinator | Contact person for the Plan of Correction and informal conference |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Sep 16, 2014
Visit Reason
The inspection was conducted as a final complaint/incident investigation following complaints and incidents reported at Senior Star at Elmore Place ALPD, Davenport, Iowa.
Findings
The investigation identified a regulatory insufficiency related to staffing. Multiple tenant files were reviewed, and incidents involving falls, elopement, medication administration, weight loss, and staff interactions were documented. No other regulatory insufficiencies were noted in medication, weight loss, antagonizing tenants, needle marks, or hospice care.
Complaint Details
The complaint investigation involved three complaint/incident intakes (#48318-C, #49321-I, #49882-I). The investigation substantiated a regulatory insufficiency in staffing. Other complaints related to medication monitoring, weight loss, antagonizing tenants, needle marks, and hospice care were reviewed but no regulatory insufficiencies were found.
Deficiencies (1)
| Description |
|---|
| Regulatory insufficiency related to staffing was noted. |
Report Facts
Census: 37
Number of tenants with cognitive disorder: 37
Number of tenants without cognitive disorder: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Buchholz | Director of Memory Care | Named in relation to the complaint investigation and findings |
| Margaret Kaltefleiter | RN MS | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Dec 4, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that Tenant #1 tripped and suffered a fracture after getting foot stuck in a dog bowl.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 sustained a left proximal humeral fracture after a fall. Staff and management responded appropriately, and sufficient staffing was confirmed to meet tenant needs.
Complaint Details
Complaint involved Tenant #1 tripping and falling due to foot getting stuck in a dog bowl, resulting in a fracture. The complaint was investigated and found to have no regulatory insufficiencies.
Report Facts
Census: 27
Age: 89
Date: May 2, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor of the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of cover letter transmitting the report |
| Amanda Buchholz | Director of Memory Care | Named in report as facility director involved in incident response |
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 0
Jul 24, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation and complaint/incident revisit for Senior Star at Elmore Place Memory Care in response to complaints and incidents reported.
Findings
No regulatory insufficiencies were identified during the investigation. The program was found to be in full compliance with administrative rules and was issued a Standard Certification. Multiple areas including tenant rights, policies and procedures, staffing, and retaliation were reviewed with no regulatory insufficiencies noted.
Complaint Details
The complaint investigation involved allegations related to tenant rights violations, insufficient staffing, and a retaliation claim where a staff member was allegedly fired for reporting suspected dependent adult abuse. The investigation found no regulatory insufficiencies and did not substantiate the retaliation allegation.
Report Facts
Number of tenants with cognitive disorder: 16
Total census of Assisted Living Program: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
| Amanda Buchholz | Administrator | Administrator of Senior Star at Elmore Place Memory Care |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 5
May 1, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant rights, policies and procedures, and staffing at Senior Star at Elmore Place Memory Care.
Findings
The report found repeated regulatory insufficiencies in tenant rights, policies and procedures, and staffing. Specific incidents involving tenants and staff were investigated, including allegations of sexual abuse and physical abuse, with some substantiated regulatory insufficiencies noted. The program was assessed a civil penalty and placed under conditional operation.
Complaint Details
The complaint investigation involved multiple allegations including tenant #10 discussing sexual activity with a staff member, and an incident involving tenant #12 being physically restrained and injured by staff. The investigation found no evidence of sexual abuse but substantiated violations of tenant rights and inadequate staff response during the incident with tenant #12.
Deficiencies (5)
| Description |
|---|
| Failure to comply with regulatory requirements related to tenant rights, policies and procedures, and staffing. |
| Program failed to follow policy on responding to tenants exhibiting aggressive behaviors and failed to keep medication room locked at all times. |
| Staff violated Tenant #12's rights during an incident involving physical restraint and refusal to allow phone use. |
| Program policies and procedures did not meet minimum standards related to reporting incidents including allegations of dependent adult abuse. |
| Insufficient number of trained staff available at all times to meet tenants' identified needs. |
Report Facts
Civil penalty amount: 2500
Reduced civil penalty amount: 1625
Census: 19
Tenants without cognitive disorder: 6
Tenants with cognitive disorder: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Mentioned in relation to civil penalty payment and contact for questions. |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter and report. |
| Hal Chase | RN BSN MPH | Monitor for the complaint/incident investigation. |
| Lori Miner | RN BSN | Monitor for the complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 11
Apr 2, 2013
Visit Reason
The inspection was conducted as a Final Recertification Monitoring Evaluation, Complaint/Incident Investigation, and Investigation Revisit following complaints and regulatory insufficiencies identified in April 2013.
Findings
The report found multiple regulatory insufficiencies related to evaluation, service plans, criteria for admission and retention, medications, staffing, nurse review, life safety, structural requirements, food service, and dementia-specific education. Several tenants had incidents including falls and injuries, and the program failed to comply with regulatory requirements leading to a $5,000 civil penalty.
Complaint Details
The complaint investigation included incidents involving tenant falls, injuries, and inadequate care. Specific complaints included Tenant #6 falling and sustaining a subdural hematoma, Tenant #8 falling and sustaining broken ribs, and Tenant #7 exhibiting aggressive and combative behavior. The program was found to have multiple regulatory insufficiencies related to these incidents and care practices.
Deficiencies (11)
| Description |
|---|
| Failure to complete functional, cognitive, and health evaluations within 30 days of admission and with changes in condition. |
| Failure to complete service plans within 30 days of admission and to individualize service plans to meet tenant needs. |
| Failure to meet criteria for admission and retention for several tenants. |
| Failure to administer medications according to regulatory requirements and failure to wash or sanitize hands prior to medication administration. |
| Insufficient number of trained staff to meet tenant needs and failure to monitor placement of wander-guard devices. |
| Failure to complete 90-day nurse reviews as required. |
| Failure to have written procedures regarding alarm systems and staff response for elopement or wandering behavior. |
| Failure to maintain building and grounds in a clean, safe, and sanitary condition. |
| Failure to provide annual food safety and sanitation training for food service personnel. |
| Failure to provide required dementia-specific education and training to staff within 30 days of employment. |
| Failure to comply with plan of correction requirements including evaluations, service plans, and staff training. |
Report Facts
Civil penalty amount: 5000
Reduced civil penalty amount: 3250
Census: 17
Tenants with cognitive disorder: 16
Tenants without cognitive disorder: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact person for appeals and hearings related to the civil penalty. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter. |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation. |
| Rose Boccella | MA | Monitor for the complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 8
Dec 26, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant safety, care, and regulatory compliance at Senior Star at Elmore Place Memory Care.
Findings
The investigation found multiple regulatory insufficiencies in areas including Criteria for Admission and Retention, Evaluation, Service Plans, Medications, Staffing, Nurse Review, Life Safety, and Structural Requirements. Specific issues involved tenant elopement, inadequate monitoring, incomplete evaluations, medication administration errors, and insufficient staff training and supervision.
Complaint Details
The complaint investigation was initiated due to an incident where Tenant #1 was found outside the program without staff knowledge. The investigation substantiated multiple regulatory insufficiencies related to tenant safety, care planning, medication administration, staffing, and environmental safety.
Deficiencies (8)
| Description |
|---|
| Failure to comply with Criteria for Admission and Retention, including inadequate monitoring and response to tenant elopement and exit seeking behavior. |
| Incomplete or untimely functional, cognitive, and health evaluations for tenants. |
| Service plans did not establish individualized interventions related to wandering, exit seeking, combative behavior, or other tenant needs. |
| Medication administration records showed multiple errors and omissions in recording medications given to tenants. |
| Staffing issues including insufficient monitoring of tenants, failure to check placement of security devices, and inadequate staff training. |
| Nurse reviews were not consistently completed every 90 days or after significant changes in tenant condition. |
| Life safety concerns including failure to maintain door alarms and pagers, and lack of policy for monitoring exterior door alarms and paging systems. |
| Structural deficiencies such as damaged child proof locks on cabinet doors and unsecured cleaning chemicals accessible to tenants. |
Report Facts
Civil penalty amount: 4500
Reduced civil penalty amount: 2925
Number of tenants at time of visit: 19
Number of tenants with cognitive disorder: 18
Number of tenants without cognitive disorder: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact person for questions regarding the complaint investigation and civil penalty. |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 0
Oct 16, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant activated the alarm system while exiting the building, prompting staff response and tenant redirection.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 exited the building but was safely returned inside without injury. Staff followed policies and procedures appropriately, and the program maintained adequate staffing and safety measures.
Complaint Details
The complaint involved a tenant activating the alarm while exiting the building. Staff responded promptly, monitored the tenant, and no harm occurred. The incident was documented and reviewed with no regulatory insufficiencies noted.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 19
Total population of program at time of on-site visit: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor of complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor of complaint/incident investigation |
| Carla Popp | Director of Memory Care | Named as facility director and interviewed during investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for the report |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Sep 19, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations of inappropriate behaviors between tenants and concerns about evaluations and service plans at Senior Star at Elmore Place ALPD.
Findings
The investigation found regulatory insufficiencies in evaluation, tenant documents, service plans, and structural requirements. Several tenant files showed incomplete or missing evaluations and service plans, and incidents involving tenant behaviors were documented. No physical harm was found in some incidents, but documentation and follow-up were lacking.
Complaint Details
The complaint alleged inappropriate behaviors between tenants and that a tenant required more than one staff for care. The investigation substantiated regulatory insufficiencies related to evaluations, service plans, and documentation for multiple tenants, including incidents involving tenants #1, #2, #4, #5, #6, and #8.
Deficiencies (1)
| Description |
|---|
| Regulatory insufficiencies in evaluation, tenant documents, service plans, and structural requirements. |
Report Facts
Census: 21
Civil penalty amount: 3000
Civil penalty reduced amount: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carla Popp | Director of Memory Care | Named in relation to the facility and findings |
| Stephanie Cummins | Monitor | Complaint/Incident investigator |
| Margaret Kaltefleiter | Monitor, RN MS | Complaint/Incident investigator |
| Jim Berkley | Program Coordinator | Contact for appeal and follow-up on Plan of Correction |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 8
Feb 1, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation for Senior Star at Elmore Place Memory Care in response to complaints and incidents reported, including regulatory insufficiencies in program reporting, evaluation, criteria for admission and retention, and service plans.
Findings
The investigation found multiple regulatory insufficiencies related to program reporting, staff response to elopements, fall interventions, emergency response system use, evaluation of tenants, criteria for admission and retention, service plans, and nurse review. Several tenants eloped without proper reporting, and some service plans and evaluations were incomplete or not updated. A $1,000 civil penalty was assessed.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in multiple areas including tenant elopements not reported, inadequate fall interventions, incomplete evaluations, and deficient service plans. The Program was assessed a $1,000 civil penalty.
Deficiencies (8)
| Description |
|---|
| Regulatory Insufficiency in Program Reporting to Department |
| Failure to notify director or designee within 24 hours of tenant elopement |
| Fall interventions were needed but not always implemented |
| Failure to provide adequate personal emergency response system access and monitoring |
| Failure to complete evaluations as needed |
| Failure to meet criteria for admission and retention regarding two-person transfers and gait belt use |
| Service plans not updated or individualized to tenant needs |
| Failure to complete nurse reviews after injury and fall |
Report Facts
Civil penalty amount: 1000
Number of tenants at time of on-site visit: 20
Number of tenants with cognitive disorder: 18
Number of tenants without cognitive disorder: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sally Hill | Director of Memory Care | Named as Director of Memory Care at Senior Star at Elmore Place Memory Care |
| Stephanie Cummins | Monitor | Complaint/Incident investigator |
| Margaret Kaltefleiter | RN MS Monitor | Complaint/Incident investigator |
| Jim Berkley | Program Coordinator | Contact for appeal and civil penalty payment |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 5
Jan 3, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation regarding allegations of inappropriate touching and other incidents involving tenants at Senior Star at Elmore Place Memory Care.
Findings
The investigation found that the program did not complete incident reports timely, did not consistently document visual checks on tenants, and failed to follow staffing policies related to tenant monitoring. No injuries or physical evidence of sexual abuse were found, but regulatory insufficiencies were noted in incident reporting and monitoring procedures.
Complaint Details
The complaint involved allegations of inappropriate touching from one tenant to another. The program reported no injury occurred and no history of inappropriate touching. The investigation included monitoring observations, nurse review, and file reviews. The complaint was investigated with findings of regulatory insufficiencies but no substantiated abuse.
Deficiencies (5)
| Description |
|---|
| The program did not complete incident reports for the incident between Tenant #1 and Tenant #2 at the time of the incident. |
| Checks were not consistently documented as completed throughout December 2011 on all shifts for Tenant #1 and Tenant #2. |
| The program did not follow the Staffing Policy related to tenant checks. |
| The program's policies and procedures did not meet minimum standards for reporting incidents including allegations of dependent adult abuse. |
| A nurse review was not completed as documented for Tenant #1 at the time of the incident and was not completed as needed. |
Report Facts
Number of tenants without cognitive disorder: 2
Number of tenants with cognitive disorder: 18
Total Population of Program at time of on-site: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter for the report |
| Stephanie Cummins | MA | Monitor for the complaint/incident investigation |
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
| Sally Hill | Director of Memory Care | Named in relation to the facility and incident |
Inspection Report
Monitoring
Census: 14
Deficiencies: 1
May 18, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction in response to a Preliminary Recertification Monitoring Evaluation Report and to ensure compliance with regulatory requirements for the assisted living program.
Findings
The evaluation found that the program did not receive any regulatory insufficiencies during the certification period. However, a regulatory insufficiency was noted related to dementia-specific training for staff, where three of five staff files did not include the required eight hours of dementia-specific education within 30 days of employment. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (1)
| Description |
|---|
| Regulatory Insufficiency: All personnel employed by or contracting with a dementia-specific program shall receive a minimum of eight hours of dementia-specific education and training within 30 days of either employment or the beginning date of the contract. |
Report Facts
Total Population of Dementia Specific Program: 14
Total Census of Assisted Living Program: 14
Staff files reviewed: 5
Staff not meeting training requirement: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sally Hill | RN Director | Director of Senior Star Memory Care at Elmore Place, mentioned in relation to the program and findings. |
| Stephanie Cummins | MA | Monitor for the evaluation. |
| Margaret Kaltefleiter | RN MS | Monitor for the evaluation. |
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 3
Jan 25, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Senior Star at Elmore Place Memory Care to investigate allegations related to occupancy agreement violations, tenant evaluation, exclusion criteria, confidentiality of tenant records, involuntary transfer protocol, and service plan compliance.
Findings
The investigation found no regulatory insufficiencies related to occupancy agreements, tenant exclusion, involuntary transfer, or confidentiality of tenant records. However, regulatory insufficiencies were noted in the evaluation of tenants and documentation of authorizations for release of information. The service plan was not signed appropriately after updates reflecting significant changes.
Complaint Details
The complaint investigation was triggered by allegations that the program did not follow occupancy agreement discharge procedures, failed to evaluate tenants properly, discharged tenants without appropriate interventions, did not uphold confidentiality of tenant records, failed to follow involuntary transfer protocols, and did not properly update service plans. The investigation reviewed tenant files, staff interviews, and documentation related to these allegations.
Deficiencies (3)
| Description |
|---|
| A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed with significant change; evaluations were not completed as required. |
| Documentation for each tenant shall include authorizations for the release of information; documentation was incomplete. |
| If a significant change triggers review and update of the service plan, the updated plan shall be signed and dated by all parties; the service plan was not signed appropriately. |
Report Facts
Total Population of Dementia Specific Program: 12
Total Census of Assisted Living Program: 12
Number of tenants discharged in past three months: 5
Number of tenants reviewed for discharge files: 3
Number of tenants involved in confidentiality allegation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation |
Inspection Report
Original Licensing
Census: 1
Deficiencies: 4
Aug 31, 2009
Visit Reason
The visit was conducted as an Initial Certification Monitoring Evaluation and Incident Investigation at Senior Star at Elmore Place to review regulatory insufficiencies and incident reports.
Findings
The program had several regulatory insufficiencies related to service plan development and staffing, including failure to consistently update service plans, develop individualized plans, and provide sufficient trained staff. Incident investigations revealed tenant falls resulting in fractured hips and issues with staff response and medication administration.
Complaint Details
The investigation included incident allegations #24261-I and #22975-I involving tenant falls resulting in fractured hips. Staff response and use of bed alarms were reviewed. Staff #2 and #3 were terminated due to a safety violation related to these incidents.
Deficiencies (4)
| Description |
|---|
| The program did not consistently update each tenant's service plan as needed when a tenant requires personal or health related care. |
| The program did not consistently develop a service plan for each tenant based on evaluations. |
| The program did not consistently develop individualized service plans indicating service providers other than the program. |
| The program did not consistently provide sufficient trained staff available at all times to fully meet tenant's identified needs. |
Report Facts
Current number of tenants in Dementia Specific Program with cognitive disorder: 1
Current number of tenants without cognitive disorder: 0
Total Population: 1
Incident date: 2009
Incident date: 2009
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leslie Dick | Executive Director | Named in report heading and involved in incident response |
| Candy Blake | Director of Memory Care | Named in report heading |
| Stephanie Cummins | Monitor | Conducted the monitoring evaluation and incident investigation |
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