Inspection Reports for Senior Star at Elmore Place

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.

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 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 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.

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

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.

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.

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.

Investigation of Incident #112363-I at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation.

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

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.

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 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 inspection was conducted as an investigation of complaints/incidents related to tenant care and safety at Senior Star at Elmore Place Memory 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.

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 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.

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.

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 inspection was conducted as an onsite infection control survey for an Assisted Living Program for People with Dementia.

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

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.

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.

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.

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.

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.

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.

No regulatory insufficiencies were cited during the recertification visit or the investigation into the incident.

Investigation of Complaint #81092-C and Incident #81155-I at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation of the complaint and incident.

Investigation of Complaint #81092-C and Incident #81155-I found no regulatory insufficiencies.

Investigation into Complaint #73448-C regarding the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation into Complaint #73448-C found no regulatory insufficiencies.

Investigation of Incident #71122-I at the assisted living program for people with dementia.

No regulatory insufficiencies were cited during the investigation of Incident #71122-I.

Investigation of Incident #71122-I with no regulatory insufficiencies cited.

Investigation of Incident #67951 at the assisted living program.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #67951; no regulatory insufficiencies found.

Investigation of Complaint #64690-C at the assisted living facility Senior Star at Elmore Place.

No regulatory insufficiencies were cited during the complaint investigation.

Complaint #64690-C was investigated and found to have no regulatory insufficiencies.

Investigation of Complaint #64690-C at the assisted living facility Senior Star at Elmore Place.

No regulatory insufficiencies were cited during the investigation of the complaint.

Complaint #64690-C was investigated and found to have no regulatory insufficiencies.

Investigation of Complaint #57972 regarding the Assisted Living Program at Senior Star at Elmore Place.

No regulatory insufficiencies were cited during the investigation of the complaint. The census at the time was 36 residents, all with cognitive disorder.

Complaint #57972 was investigated and found to have no regulatory insufficiencies.

The inspection was conducted as a complaint/incident investigation related to staffing concerns at Senior Star at Elmore Place, Davenport, IA.

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.

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.

The inspection was conducted as a complaint/incident investigation following allegations related to admission/discharge and staffing at Senior Star at Elmore Place.

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.

Allegations of admission/discharge issues and staffing concerns were investigated and found unsubstantiated.

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.

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.

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.

The inspection was conducted as a final complaint/incident investigation following complaints and incidents reported at Senior Star at Elmore Place ALPD, Davenport, Iowa.

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.