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.