Legend at Silver Creek.

“The gate in the courtyard of the Secured Dementia Care Unit would not open after multiple attempts of entering the keypad instructions, blocking egress from the courtyard to the parking lot.”

“A laptop on a medication cart containing resident medical information for Residents #1 and #2 was unlocked, unattended, and accessible on the first floor, violating record confidentiality requirements.”

“Staff Member A and Staff Member B, hired in 2025, did not receive required annual training in medication self-administration training during training year 2025.”

“Poisonous materials including body wash, laundry detergent, toothpaste, and shave gel were unlocked, unattended, and accessible in Resident #3's room. Resident #3 has been assessed as incapable of recognizing and using poisons safely.”

“Hot water temperatures in resident bathrooms exceeded the maximum allowable 120°F: 129.4°F in room #316, 133.3°F in room #306, 137.1°F in room #221, 137.2°F in room #218, and 137.9°F in room #109.”

“The home's written emergency procedures have not been reviewed and submitted to the local emergency management agency since March 26, 2024.”

“Staff Person B physically prevented a resident in a wheelchair from leaving the dining room by blocking them, locking the wheelchair wheels, repositioning the resident, and jolting the wheelchair back. The resident was visibly upset and distressed, repeatedly yelling. Staff Person B continued providing unsupervised care until 10:00 PM despite the incident being reported, as the home did not immediately develop and implement a plan of supervision or suspend the staff person.”

“A resident fall resulting in a fracture of the left radius and ulna that occurred on 2/9/25 was not reported to the Department within 24 hours as required. This is a repeated violation.”

“A resident with an assessment requiring 2 showers per week did not receive the required number of showers during four separate weeks: received only 1 shower during the week of 12/8/24-12/14/24, only 1 shower during 12/22/24-12/28/24, only 1 shower during 1/12/25-1/18/25, and no showers during 12/29/24-1/4/25.”

“Staff Person B physically abused a resident by preventing them from leaving the dining room, blocking their exit, locking the wheelchair wheels, repositioning the resident, and jolting the wheelchair while laughing at the resident's distress. This is a repeated violation.”

“The home's current violation reports dated 4/30/24, 5/21/24, and 7/11/24 were not posted in a conspicuous and public place in the home.”

“During the overnight shift with 96 residents present, only 1 staff person was certified in First Aid and CPR, violating the requirement of at least one certified staff member per 50 residents.”

“Staff persons A and B who began working in 2024 did not receive required first-day orientation on fire safety, evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety, fire extinguisher use, smoke detectors, and emergency service notification.”

“Staff persons A and B did not complete required 40-hour orientation training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“Food was not stored off the floor at the facility.”

“Loose medications were found improperly stored: a large round pink pill on the first-floor medication room floor and two loose pills in the second-floor medication cart, indicating medications were not stored in an organized manner under proper conditions.”

“Multiple prescribed medications were not available in the home when needed: Resident 1's Modafinil 200 mg was unavailable from 7/1/24-7/11/24; Resident 2's Basaglar and FIASP were not available on 7/8/24 at 5:00 PM, preventing administration of prescribed doses.”

“Medication Administration Records (MARs) for four residents were missing required diagnosis or purpose information for prescribed medications: Resident 2's FIASP, Resident 3's Mupirocin and Senna-Doc, and Resident 4's Olmesartan Medoxomil and Omeprazole.”

“Multiple prescribed medications were not administered as ordered by prescribers: Resident 2 missed Basaglar, FIASP, Caltrate, and Mucus relief doses on 7/8/24; Resident 3 missed doses of Mupirocin, Pramipexole, Olpatadine, Acetaminophen, Dexlansoprazole, Duloxetine, and Gabapentin on various dates; Resident 5 missed Atorvastatin on 7/8/24.”

“Resident records were requested at 9:30am and again at 1:15pm, but were not provided to inspectors until 2:05pm, causing a delay in DHS access to records.”

“Two reportable incidents were not reported to the Department within 24 hours: (1) a staff member's derogatory reference to a resident due to observed sexual encounters in the Secure Dementia Care Unit, and (2) a resident's fall and head injury requiring hospital transport that was witnessed by staff.”

“A resident requiring 1:1 supervision due to sexual behaviors was left alone for approximately ten minutes, during which time staff observed the resident engaged in inappropriate sexual contact with another resident in the bathroom. Additionally, staff made derogatory comments about the resident related to sexual encounters, constituting verbal abuse.”

“Staff members stated they frequently locked resident bedroom doors in the Secured Dementia Care Unit while residents were in common areas, restricting residents' access to their bedrooms.”

“Resident assessment and support plans indicate conflicting information regarding mobility status and evacuation ability compared to medical evaluations, creating inconsistency in documented medical and behavioral care needs.”

“The facility failed to provide adequate direct care staffing for residents with mobility needs. On three dates in April 2024 (4/19, 4/21, 4/27), the facility did not provide the minimum required 114 hours of direct care services (2 hours per day for 25 residents with mobility needs), falling short by 4.5 hours, 27.5 hours, and 43 hours respectively.”

“The facility failed to ensure that at least 75% of required direct care service hours were available during waking hours. On 4/19/24, only 72% of required hours were provided during waking hours; on 4/21/24, only 53.5%; and on 4/27/24, only 62%.”

“A white pill labeled 210 was found on the floor of the Reflections dining room on 4/30/24, and on 5/1/24, the medication cart in the Reflections secured dementia care unit was unlocked, unattended, and accessible. Medications and syringes were not kept in a secured, locked container.”

“A bottle of Gabapentin 300 mg tablets belonging to Resident 1 was found in the medication cart, but there was no current order for this medication at this dosage.”

“Multiple medications prescribed as needed for residents were not available in the home. The home failed to maintain adequate supplies of prescribed medications for resident access, including expired medications that had been provided by residents.”

“Food debris was observed on several surfaces in the kitchen and floor, including pushcarts, storage containers, steam tables, and fryer area. Surfaces were not clean and free of debris post breakfast service.”

“An approximate 1-inch accumulation of lint was found in the lint trap of a dryer located on the second floor. Lint was not removed from the lint trap after use.”

“Initial medical evaluations (DME) for three residents were not completed within the required timeframe. The DMEs were completed prior to the residents' actual admission dates, exceeding the 60 days prior to admission or 30 days after admission requirement.”

“A 24 ounce clear spray bottle containing blue liquid identified only by marker as 'multi surface 8/25' was found in the 1st floor housekeeping closet without a manufacturer's label. Poisonous materials must be stored in their original, labeled containers.”

“A steam table was observed in the Secured Dementia Care Unit's kitchen without protective guards in place to prevent residents from coming in contact with the heat source.”

“The temperature in the cinema's refrigerator was 44 degrees Fahrenheit at 10:05 AM and 48 degrees Fahrenheit at 10:21 AM on 09/26/2023. Food requiring refrigeration must be stored at or below 40 degrees Fahrenheit.”