Silver Creek Inn Memory Care Community.

“Based on documentation review and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice violated a resident's rights.  Findings include:  1. A review of Department documentation revealed a report that stated R1 was berated by E1. According to the report, E1 stated, "You stink;" "You will not be let out until you take a shower;" and "You have not taken a shower in a month." 2. A review of the facility’s documentation revealed a witness statement from E5. E5 reported that E1 stated, "You stink;" "You will not be let out until you take a shower;" and "You have not taken a shower in a month." 3. In an interview with E5, E5 confirmed E5’s statement in the witness statement.  4. In an interview, E4 acknowledged that R1 was not treated with dignity, respect, and consideration. 5. In an exit interview, the findings were reviewed with E4, and no additional information was provided. 6. This is a repeat deficiency from the complaint inspection conducted on May 23, 2024.”

“Based on documentation review and interview, the manager failed to ensure that a resident was not subjected to restraints. The deficient practice posed a risk of injury and violated a resident’s rights.     Findings include: 1. R9-10-101.202 defines “Restraint” as any physical or chemical method of restricting a patient’s freedom of movement, physical activity, or access to the patient’s own body. 2. A review of Department documentation revealed a report that reported E1 blocked the shower door with E1’s foot, while R1 was inside screaming to be let out.  3. A review of facility documentation revealed a witness statement from E5. E5 reported that “E1 put R1 in the shower room and put her foot against the door to prohibit R1 from leaving the shower [...].” 4. In an interview with E5, E5 confirmed E5’s statement in the witness statement about R1 being restrained.  5. In an interview, E4 acknowledged that R1 was restrained by E1.  6. In an exit interview, the findings were reviewed with E4, and no additional information was provided. 7. This is a repeat deficiency from the complaint inspection conducted on April 11, 2025.”

“Based on documentation review, record review, and interview, the manager of an assisted living home failed to maintain a standardized form for each resident that included the information prescribed in Arizona Revised Statutes (A.R.S.) § 36-420.04(A)(1-9). The deficient practice posed a risk if the emergency responder was not aware of critical health information for a resident. Findings include:  1. A.R.S. § 36-420.04.A.1-9 states, “Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: (...).”  2. A review of R1’s and R2’s medical records revealed no standardized form to provide to emergency responders.  3. In an interview, E4 acknowledged that a standardized form for emergency responders for R1’s and R2’s was not completed.    4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner. Findings include: 1. ARS § 11-593.B. states, "Reporting is required in the following circumstances: 1. Death when not under the current care of a health care provider as defined pursuant to section 36-301. 2. Death resulting from violence. 3. Unexpected or unexplained death. 4. Death of a person in a custodial agency as defined in section 13-4401. 5. Unexpected or unexplained death of an infant or child. 6. Death occurring in a suspicious, unusual, or unnatural manner, including death from an accident believed to be related to the deceased person's occupation or employment. 7. Death occurring as a result of anesthetic or surgical procedures. 8. Death suspected to be caused by a previously unreported or undiagnosed disease that constitutes a threat to public safety. 9. Death involving unidentifiable bodies." 2. Review of R3's medical record revealed the following:  -A note dated July 13, 2024, at 6:54 am that stated, “Resident was found unresponsive, police, [R3’s family member] and Atlas were notified by ED...” -A note dated "1 year ago" that stated "Found resident unresponsive at approximately 545 am while doing morning med pass." -A note dated "1 year ago" that stated, "Resident very tired, [E5] helped [R3] use the restroom [R3] had a LBM, resident very noncompliant with meds, It was very hard to get [R3] to take [R3's] Midodrine and Sinemet [R3] finally took those 2 medications but not the rest, vs BP-54/42 P-116 T 97.7 R-16 O2 87%, R3 also ate only 10% of dinner." -A note dated "1 year ago" that stated "Resident's body was taken to Arizona Medical Examiner's office at around 9:30 a.m..." -A note dated "1 year ago" stated, “R3 off alert has passed away.” Documentation was not available showing R3 received hospice services. 3. A review of Department documentation revealed no evidence that R3's death was reported to the Department. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a written service plan included documentation of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments, for three of the three residents sampled. The deficient practice posed a risk if medical or health problems were not addressed by the assisted living facility. Findings include: 1. A review of R1’s medical record revealed a current service plan dated December 2, 2025. However, the service plan did not list R1’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 2. A review of R2’s medical record revealed a current service plan dated November 5, 2025. However, the service plan did not list R2’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 3. A review of R3’s medical record revealed a current service plan dated April 23, 2024. However, the service plan did not list R3’s medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. 4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that the service plan for a resident receiving directed care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; strategies to ensure a resident's personal safety; encouragement to eat meals and snacks; documentation of resident's weight; coordination of communication with the resident’s representative, family members, and if applicable, other individuals identified in the resident’s service plan. The deficient practice posed a risk as the service plan did not reinforce and clarify the services to be provided to a resident. Findings include: 1. A review of R1’s medical record revealed the following:   A current service plan dated December 2, 2025, which indicated R1 received directed care services.  R1’s service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; strategies to ensure a resident's personal safety; encouragement to eat meals and snacks; coordination of communication with the resident’s representative, family members, and if applicable, other individuals identified in the resident’s service plan. 2. A review of R2's medical record revealed the following:  A current written service plan dated November 5, 2025, which indicated R2 received directed care services.  R2’s service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; strategies to ensure a resident's personal safety; encouragement to eat meals and snacks; coordination of communication with the resident’s representative, family members, and if applicable, other individuals identified in the resident’s service plan. 3. A review of R3's medical record revealed the following:  A current written service plan dated April 25, 2024, which indicated R3 received directed care services.  R3’s service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; incontinence care that ensures that a resident maintains the highest practicable level of independence when toileting; strategies to ensure a resident's personal safety; encouragement to eat meals and snacks; documentation of R3’s weight; coordination of communication with the resident’s representative, family members, and if applicable, other individuals identified in the resident’s service plan. 4. In an interview, E4 acknowledged that the service plans were missing these components.  5. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure that when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for two of three residents. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1’s medical record revealed a note dated August 19, 2025. The note reported R1 had an incident in which emergency services were called. Documentation was not available showing any action taken to prevent the incident from occurring in the future.  2. A review of R2’s medical record revealed the following:  A note dated November 2, 2025. The note reported that R2 had an incident in which emergency services were called. Documentation was not available showing any action taken to prevent the incident from occurring in the future.  A note dated November 22, 2025. The note reported that R2 had an incident in which emergency services were called. Documentation was not available showing any action taken to prevent the incident from occurring in the future.  3. In an interview, E4 acknowledged that the documentation was missing any action taken to prevent the incident from occurring in the future.  4. In an exit interview, the findings were reviewed with E4, and no additional information was provided.”

“Based on the documentation review, record review, and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident.   Findings include:   1.     Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body."   2.     A review of E2's personnel record revealed a document titled ' Employee Disciplinary Action Record" reporting "Employment Termination" due to "conduct detrimental to resident care or community operation and conduct inconsistent with resident rights."   3.     A review of Department documentation revealed a reported incident on March 26, 2025. The documentation indicated R1 was restrained while receiving a shower from E2. E1 reported that E2 forced R1 into the shower and E2 was restricting R1's hands, leaving marks and bruises on R1's hands.   4.      In an interview, E1 acknowledged that R1 was restrained in the shower by E2.”

“Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation (CPR) training, for one of two employees sampled. The manager also failed to ensure that a personnel record for each employee included documentation of a first aid training card for one of two employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. Record review established that E1 did not have a cardiopulmonary resuscitation (CPR) card. Record review also established that E1 did not have a first aid training card. 2. In an interview E1 confirmed that E1 did not have a cardiopulmonary resuscitation (CPR) card and that record review established that E1 did not have a first aid training card.”

“Based on documentation review and interview, the manager failed to provide documentation required by this Article within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the licensee did not provide the Department with the requested documentation required by this Article. Findings include: 1. The Compliance Officers arrived on-site at approximately 9:30 AM. The Compliance Officers provided a list of documentation needed within two hours. 2. The Compliance Officers requested the following documentation from E1 and E2 at 9:55 AM with a two hour deadline of 11:55 AM; - R1's, R2's, and R3's complete resident medical records including any incident reports - E1's, E2's, E3's, and E4's complete personnel records - Disaster Drills - Evacuation Drills - Disaster plan review - The facility's policies and procedures - Policies and Procedures review - Quality Management report - Recent Fire Inspection 3. The Compliance Officers did not receive the following documentation within the 2 hour time frame; - Resident agreement for R1, R2, and R3 - Resident rights for R1, R2, and R3 - Resident emergency orientation for R1, R2, and R3 - 90 day pre-admission for R1, R2, and R3 - Influenza and Pneumonia vaccination documentation for R1, R2, and R3 - Tuberculosis tests and screening questionnaire for R1, R2, and R3 - Disaster Drills - Evacuation Drills - Disaster plan review - Policies and Procedures review - Quality Management report - Recent Fire Inspection 4. In an interview, E1, E2 and E5 acknowledged the requested documentation was not provided within the required time frame.”

“Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for two of four employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2's personnel record revealed E2 was hired October 16, 2023. E2's personnel record revealed a negative TB skin test, however, it was read after E2 had begun providing services at the assisted living facility, and no additional documentation of freedom from infectious TB was available for review. Based on E2's hire date, this documentation was required. 4. A review of E3's personnel record revealed E3 was hired September 20, 2023. E3's personnel record revealed a negative TB skin test that was less than 12 months old, however no additional documentation of freedom from infectious TB was available for review. Based on E3's hire date, this documentation was required. 5. A review of E2's and E3's personnel records revealed no documentation for assessing risk of prior exposure to infectious tuberculosis and determining if the individual had signs or symptoms of tuberculosis that was reviewed by a medical practitioner, occupational health provider or local health agency. 6. In an interview, E1, E2 and E5 acknowledged the facility was not in compliance with R9-10-113. 7. Technical assistance was provided on this Rule during the compliance inspection conducted on July 13, 2023.”

“Based on observation, record review, documentation review, and interview, the manager failed to ensure medication was stored by the facility, for one of four residents who received medication administration. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. The Compliance Officers observed the following medications in R4's room. - Ipratropium-Albuterol Sulfate 0.5-3(2.5) MG - Acetaminophen 500 mg - ClearLax Polyethylene Glycol 3350 powder 2. A review of R4's medical record revealed a service plan dated July 26, 2024. The service plan indicated R4 required medication administration. 3. A review of the facility's policy and procedures revealed a policy titled, "Medication Services" which stated, "4. All medications for residents who receive assistance with their medications will be stored in a designated medication storage area in each building." 4. In an interview, E2 acknowledged the medication was not stored by the facility and R4 required medication administration.”

“Based on documentation review and interview, the manager failed to ensure an employee disaster drill was accurately documented. The deficient practice posed a risk as false or misleading documentation was provided to the Department. Findings include: 1. The Compliance Officers requested the disaster drills multiple times. However, E1 provided the disaster drills at 2:56 PM on August 09, 2024 along with the following disaster drills documented with future dates: - October 6, 2024 at 7 pm; - November 13, 2024 at 7:30 pm; and - December 6, 2024 at 5 am 2. In an interview, E1 and E5 acknowledged that disaster drills were provided to the Department with future dates documented.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), for one of four individuals sampled who was working as a caregiver. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. A review of the facility's policies and procedures reviewed and approved March 23, 2023 revealed a document titled, "Personnel Requirements Policy." The document stated, "Specific Licenses and Certifications: Positions requiring specific licenses or certifications must be kept current and valid to continue employment. Copies of such licenses will be kept in the employee file. The AA or Receptionist will ensure compliance is provided by accredited facility and verify validity; AA will notify employee when renewal is needed. This includes but not limited to: ...Caregiver Certification..." 2. A review of E3's personnel record (hired as a caregiver) revealed a caregiver training certificate from Arizona Healthcare Academy, dated August 13, 2020. There was no ALTP number provided on the certificate. 3. A review of the NCIA verification of caregiver training portal (https://azcg.tmutest.com) revealed E3 had not completed a caregiver training program after August 3, 2013. 4. A review of facility documentation revealed E3 was scheduled in the facility on the following dates in May 2024: - May 1, 2024-May 2, 2024; - May 4, 2024-May 9, 2024; and - May 11, 2024-May 19, 2024. 5. In an interview, E2 acknowledged that based on information reviewed with the Compliance Officer, E3 had not completed a caregiver training program after August 3, 2013.”

“Based on record review and interview, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. A review of E3's personnel record revealed an "Employee Disciplinary Record" dated January 14, 2024. The document stated, "On 1/10/24 you were observed by your superior and multiple staff members talking on your personal cell phone while on duty, sitting behind the nurses station for long periods... Multiple residents assigned to your care were noted to be soiled for long periods without your prompt attention to the matter." 2. In an interview, E2 acknowledged that the time E3 spent on E3's personal phone rather than providing resident care resulted in multiple residents remaining soiled for long periods of time. E2 acknowledged the residents were not treated with dignity, respect, and consideration.”