Silver Star Assisted Living.

“Based on documentation review, observation, record review, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to the 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.  When the Compliance Officer Supervisor and the Compliance Officer arrived at the facility, R1 was observed sitting in a wheelchair at the dining room table. A gait belt was observed secured around R1's waist and the back of the wheelchair preventing R1 from getting up.    3. A review of R1's medical record revealed a service plan for personal care services dated January 27, 2025. This service plan revealed that R1 had a diagnosis of dementia and that R1 was forgetful.   4. During an interview, E2 reported the gait belt was around the wheelchair because R1 tried to get out of the wheelchair. E1 later reported the gait belt was used to prevent R1 from falling out of the wheelchair because R1 leaned forward. E1 acknowledged the gait belt secured R1 to the wheelchair preventing R1 from getting up.     5. During an environmental inspection, the Compliance Officer Supervisor and the Compliance Officer observed R2 in bed with a bed cane positioned at the foot of the bed and a bedside table near the top of the bed.   6. A review of R2's medical record revealed a service plan for personal care services dated December 17, 2024. This service plan revealed that R2 had a diagnosis of muscle weakness and anxiety, was a fall risk, and that R2 was forgetful.   7. During an interview, E2 reported the bed cane was used to prevent R2 from getting out of bed. E1 later reported the bed cane was used so R2 would not fall out of the bed.    8. During an environmental inspection, the Compliance Officer Supervisor and the Compliance Officer observed R3 in bed with a bed cane positioned at the foot of the bed with a green foam wedge between the mattress and the bed cane and a bedside table near the top of the bed.   9. A review of R3's medical record revealed a service plan for directed care services dated February 2, 2025. This service plan revealed that R3 had a diagnosis of Alzheimer's disease and that R3 was confused and forgetful.    10. During an interview, E2 reported the bed cane was used to prevent R2 from getting out of bed. E1 later reported the bed cane was used so R3 would not fall out of bed.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of three sampled residents who received medication administration. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's service plan revealed that R1 received medication administration. 2. A review of R1's medical record revealed a medication order dated January 27, 2025, for Metoprolol Succinate 25mg one tab daily PO. 3. A review of R1's medical record revealed a February 2025 Medication Administration Record (MAR). This MAR documented Metoprolol Succinate 25mg was administered twice a day at 0800 and 1900. 4. In an interview E1 reported R1 was administered the medication as ordered. E1 acknowledged that R1's medical record did not include accurate documentation of the medication administration.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who could access the medication.   Findings include:   1. During an environmental inspection of the facility, the Compliance Officer Supervisor and the Compliance Officer observed in the kitchen, the medication cabinet that held nine residents' medications unlocked. The cabinet door had a lock; however, the cabinet door was able to be opened.   2. During an environmental inspection of the facility, the Compliance Officer Supervisor and the Compliance Officer observed in the pantry, multiple medications stored with food items including: -Glipizide; -Acetaminophen; -Mucinex sore throat spray; -Lactulose Solution; -Mucinex all in one liquid gels; and -Milk of magnesia liquid.   3. In an interview, E1 acknowledged the medications were stored unlocked and not stored in a cabinet used for only medications.”

“Based on observation and interview, the manager failed to ensure the premises at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of a resident.   Findings include: 1. During the environmental inspection, the Compliance Officer Supervisor and the Compliance Officer observed three ambulatory residents. 2. During the environmental inspection, the Compliance Officer Supervisor and the Compliance Officer observed a walking pathway in the backyard that was raised (approximately 4 inches) and did not provide an even surface. 3. In an interview, E1 acknowledged the premises at the assisted living facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury”

“Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental inspection, the Compliance Officer Supervisor and the Compliance Officer observed the following poisonous or toxic materials stored in the pantry with food: -“Raid” Roach spray; -“Febreze” Air Freshener; -“Clorox” cleaning wipes; -“Clorox Clean-up”; -“Sprayway” glass cleaner; -“Weiman” Stainless Cleaner; -“WD-40”; -“Lysol” toilet cleaner; -“Great Value” bleach; -"Family Guard” disinfectant spray; and -“Fabuloso” multi-purpose cleaner. 3. During an interview, E1 acknowledged the toxins were in stored the pantry, and were not stored separately from the food items.”

“Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R1's medical record revealed a medication order dated October 25, 2023 for "Dicyclomine 10 mg (milligrams), 1 cap four times a day." 2. A review of R1's medical record revealed a medication administration record (MAR) dated October 2023. The MAR reflected R1 was administered one capsule of "Dicyclomine 10 mg" three times a day. 3. The Compliance Officer observed R1's medication organizer, which contained "Dicyclomine" in the morning, noon, and bedtime slots. 4. In an interview, E1 reviewed and acknowledged R1's "Dicyclomine" was not administered according to the medication order in R1's medical record.”