Silver Creek Leisure Living

Based on documentation review, record review, and interview, the manager failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C)(2), for two of four personnel sampled. Findings include: 1. A.R.S. § 36-411(C) states: "C. Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: ... 2. Verify the current status of a person's fingerprint clearance card." 2. A review of E2’s and E3’s personnel records revealed valid fingerprint clearance cards; however, no documentation verifying the current status of each individual’s fingerprint clearance card was available for review. 3. A review of the Arizona Department of Public Safety (DPS) web portal at https://psp.azdps.gov/services/cardStatusRequest revealed valid fingerprint clearance cards for E2 and E3. 4. In an interview, E1 and E5 acknowledged documentation of compliance with A.R.S. § 36-411(C)(2) for E2, and E3 was not available for review. This is a repeat deficiency from the compliance inspection conducted on June 12, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record included documentation of a caregiver's and an assistant caregiver’s verified skills and knowledge for two of the two employees sampled. The deficient practice posed a risk as the required information could not be verified for E2 and E3. Findings include: 1. A review of E2’s personnel record revealed that E2 had been hired as an assistant caregiver; however, the record did not contain documentation verifying E2’s skills and knowledge. 2. A review of E3’s personnel record revealed that E3 had been hired as a caregiver; however, the record did not contain documentation verifying E3’s skills and knowledge. 3. In an interview, E1 and E5 reported that the facility verified skills and knowledge upon hire using a skills checklist; however, E1 and E5 acknowledged that E2’s and E3’s personnel records did not contain documentation verifying their skills and knowledge.

Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of four residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R1's acceptance date, this document was required. 2. A review of R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this document was required. 3. In an interview, E1 acknowledged that R1's and R2's medical records did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the residents required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was documented in the resident's medical record, for one of three residents sampled receiving medication administration. The deficient practice posed a risk as the medication could not be verified as administered against a medication order. Findings include: 1. A review of R4's medical record revealed a signed medication order dated May 29, 2025. The medication order stated the following: "Humalog KwikPen 100 unit/1 mL Insulin Pen. Inject per sliding scale: 151–200 = 2U; 201–250 = 4U; 251–300 = 6U; 301–350 = 8U; 351–400 =10U; Greater than 400 = 12U, call physician. Four times daily before meals and at bedtime." 2. A review of R4's medical record revealed a July and August 2025 medication administration record (MAR) that revealed R3's blood sugar reading was taken at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM, and Humalog KwikPen 100 unit/1 mL Insulin Pen was administered from July 27, 2025, to the present. However, documentation was not available showing how many units of insulin were administered on the days listed below, according to the medication order: - Date 7/27, Time 8 PM, Results 175, No units documented. - Date 7/28, Time 8 PM, Results 168, No units documented. - Date 7/29, Time 8 PM, Results 276, No units documented. - Date 7/30, Time 4 PM, Results 173, No units documented. - Date 7/30, Time 8 PM, Results 197, No units documented. - Date 7/31, Time 8 PM, Results 186, No units documented. - Date 8/1, Time 8 PM, No Results, No units documented. - Date 8/2, Time 8 PM, No Results, No units documented. - Date 8/6, Time 8 PM, Results 177, No units documented. - Date 8/7, Time 11 AM, Results 210, No units documented. - Date 8/7, Time 8 PM, Results 179, No units documented. - Date 8/8, Time 8 PM, No Results, No units documented. - Date 8/9, Time 8 PM, Results 269, No units documented. - Date 8/11, Time 8 PM, Results 225, No units documented. 3. In an interview, E1 and E5 reported that the medication was administered per the medication order. However, the exact units that were given to R4 were not documented on the MAR.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for pneumonia, according to A.R.S. § 36-406(1)(d), for three of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1’s, R2’s, and R3’s medical records revealed that R1, R2, and R3 were offered the flu vaccine in 2024; however, documentation showing whether the residents received or refused the pneumonia vaccine was not available for review. 3. In an interview, E1 and E5 acknowledged that R1’s, R2’s, and R3’s medical records did not contain documentation of their notification of the availability of the pneumonia vaccine or whether they received or refused the pneumonia vaccine, as required by A.R.S. § 36-406(1)(d). This is a repeat deficiency from the compliance inspection conducted on June 15, 2023.

Based on record review and interview, the manager failed to ensure that a service plan included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections for one of two sampled residents who received personal care services. The deficient practice posed a health risk to the resident if skin maintenance was not provided to ensure the health and safety of a resident. Findings include: 1. A review of R1's medical record revealed a current written service plan for personal care services dated July 09, 2025. The service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. 2. In an interview, E1 and E5 acknowledged that R1's service plan did not include skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections.

Based on record review and interview, the manager failed to ensure a service plan for a resident receiving personal care services included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections; and offering sufficient fluids to maintain hydration, for one of two residents sampled who received personal care services. The deficient practice posed a risk as the service plan did not include services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan for personal care services dated July 09, 2025. This service plan did not include documentation of offering sufficient fluids to maintain hydration. 2. In an interview, E1 and E5 acknowledged that R1's service plan did not include documentation of offering sufficient fluids to maintain hydration.

Based on record review and interview, the manager failed to ensure the service plan for a resident receiving directed care services included the requirements in R9-10-815(C)(1-7), for one of one residents sampled receiving directed care. The deficient practice posed a health risk to the resident. Findings include: 1. A review of R2's medical record revealed a service plan, dated June 28, 2025, for directed care services. However, this service plan did not include skin maintenance to prevent bruises, injuries, pressure sores, and infections; offering sufficient fluids to maintain hydration; strategies to ensure a resident's personal safety; cognitive stimulation and activities to maximize functioning; documentation of the resident's weight, or documentation from a medical practitioner stating that weighing the resident was contraindicated; and coordination of communications with the resident's representative and/or family members. 2. During an interview, E1 and E5 reported that R2 received directed care services and acknowledged that the service plans did not include the above-mentioned requirements in R9-10-815(C) (1-7).

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During the environmental tour, the Compliance Officer observed that the facility provided medication administration services. 2. A review of facility policies and procedures revealed a Medication policy. However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an interview, E1 and E5 acknowledged that the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95° F and 120° F in the areas of the facility used by residents. The deficient practice posed a health and safety risk to the residents. Findings include: 1. During the environmental inspection of the facility with E5, the Compliance Officer observed the hot water temperature at 125° F in the common bathroom on the first floor. 2. During the environmental inspection of the facility with E5, the Compliance Officer observed the hot water temperature at 135.6° F in the resident bathroom (Room 110) on the first floor. 3. In an interview, E1 and E5 acknowledged that the hot water temperature was not maintained between 95° F and 120° F in the areas of a facility used by residents.

Based on observation and interview the manager failed to ensure that cooling systems maintained the assisted living facility at a temperature between 70\'b0 F and 84\'b0 F at all times. Findings include: 1. During an interview E1 stated, "Our air conditioning for the third floor common hallway is not working properly." 2. At the time of the survey the temperature in the third floor common hallway was observed to be 93 degrees Fahrenheit. 3. During an interview E1 acknowledged the cooling systems failed to maintain the assisted living facility at a temperature between 70\'b0 F and 84\'b0 F at all times.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a fall prevention and recovery training program including initial training and continued competency training. 2. During an interview, E1 acknowledged the required documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on June 15, 2023.

Based on record review and interview, the governing authority failed to ensure that one of three sample employees had a current and valid fingerprint clearance card. Findings include: 1. The record for E2 (start date April 5, 2018) contained a DPS fingerprint clearance card that expired on May 21, 2024. Documentation was present in the record reflecting that DPS was contacted on June 3, 2024 to renew the fingerprint clearance card; however, there was not a current fingerprint clearance card in the personnel record. 2. During an interview, E1 acknowledged the required documentation was not in the record.

Based on record review, observation and interview, the manager failed to ensure that two of two sample service plans for residents who were storing medication in their bedrooms included how the medication would be stored and controlled. Findings include: 1. During an interview, E1 indicated that R2 self-administered their own medications and stored the medications in their room. 2. The record for R2 contained a service plan dated May 12, 2023 that did not include how the resident's medication would be stored and controlled. 3. During an interview, E1 indicated that R3 self-administered their own medications and stored the medications in their room. 4. The record for R3 contained a service plan dated October 31, 2023 that did not include how the resident's medication would be stored and controlled. 5. During an interview, E1, acknowledged the service plans did not indicate how the resident's medication would be stored and controlled in their rooms.

Based on record review and interview, the manager failed to ensure that one of two sample resident records had a written service plan that was reviewed and updated at least once every 12 months for a resident receiving supervisory care services. Findings include: 1. Review of the record for R2 revealed that the last service plan review was dated May 12, 2023. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plan was reviewed and updated at least once every twelve months.

Based on observation and interview, the manager failed to ensure that a current drug reference guide was available for use by personnel members. Findings include: 1. The drug reference guide available for review was the Nursing Drug Handbook, copyright date 2023. 2. The Internet web site for the drug reference guide revealed that a more current edition was available for distribution. 3. During an interview, E1 stated, "That's the most current one I have."

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E1 acknowledged that the required documentation was not available for review. This is a repeat deficiency from the compliance inspection conducted on June 15, 2023.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Facility disaster drill documentation revealed that the last disaster drill was conducted on July 12, 2023. No other disaster drill documentation was available for review. 2. During an interview, E1 acknowledged that documentation failed to reflect that employee drills were conducted on each shift, at least once every three months. This is a repeat deficiency from the compliance inspection conducted on June 15, 2023.

Based on documentation review and interview, the manager failed to ensure that unless the assisted living center has documentation of having received an exception from the Department before October 1, 2013, a fire alarm system was installed according to the National Fire Protection Association 72 and was in working order and a sprinkler system was installed according to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems and was in working order. Findings include: 1. During an interview, E1 indicated that the facility was equipped with a fire alarm system but was not equipped with sprinkler system. 2. Review of Department documentation showed that the facility had been granted an exemption from the fire sprinkler system requirement; however, this exemption required the facility to complete a Fire Safety Evaluation System (FSES) and keep the FSES updated. 3. No FSES documentation was available for review. 4. During an interview, E1 stated, "I don't have that." This is a repeat deficiency from the compliance inspection conducted on June 15, 2023.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal documentation indicating that the health care institution had established and documented tuberculosis infection control activities that included subsections a. through f. of this rule. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E2 indicated that the last documentation indicating that annual TB training had been conducted was on April 10, 2023. 2. Review of the record for E3 indicated that the last documentation indicating that annual TB training had been conducted was on June 8, 2023. 3. During an interview, E1 acknowledge that the required documentation was not available.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S.36-420.01. Findings include: 1. Review of the record for E1 (hired 1984), failed to reveal documentation of fall prevention and fall recovery training. 2. Review of the record for E2 (hired October 3, 2018), failed to reveal documentation of fall prevention and fall recovery training. 3. Review of the record for E3 (hired September 12, 2014), failed to reveal documentation of fall prevention and fall recovery training. 4. During an interview, E1 indicated that training for fall prevention and fall recovery had not been developed and administered to staff.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "quarterly" basis. 2. No reports were available for review. 3. During an interview, E1 stated, "I haven't done those reports yet."

Based on record review and interview the manager failed to ensure that one of three sample resident records contained service plans that when updated were signed and dated by the resident or resident's representative. Findings include: 1. The record for R3, contained service plans dated January 19, 2023 and February 28, 2023 that did not contain the dated signature of the resident or the resident's representative. 2. During an interview, E1 acknowledged that the service plans did not reflect the required dated signature.

Based on record review and interview, the manager failed to ensure that two of three sample resident records contained documentation of notification to the resident of the availability of vaccinations for influenza and pneumonia. Findings include: 1. The record belonging to R1 contained documentation indicating that the resident was last notified of the availability of the pneumonia vaccination on January 11, 2022. No additional documentation indicating when the resident had been offered, refused or received the vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 2. The record belonging to R3 contained no documentation indicating that the resident had been notified of the availability of either the influenza or pneumonia vaccination on a yearly basis. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required. 3. During an interview, E1 acknowledged that the vaccinations had been made available to the resident on a yearly basis however the record did not contain the required documentation.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the Toxicology Handbook, 3rd. edition. 2. The Internet web site for the toxicology guide revealed that a more current edition was available for distribution. 3. During an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on documentation review and interview, the manager failed to ensure that the disaster plan was reviewed at least once every 12 months. Findings include: 1. Review of facility documentation failed to reveal that the disaster plan had been reviewed at least once every 12 months. 2. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. Twelve months of facility disaster drill documentation was requested. Review of the disaster drill documentation provided revealed that disaster drills were conducted for each shift on the following dates: January 17, 2023, October 7, 2022 and July 7, 2022. No other disaster drill documentation was available for review. 2. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that an evacuation drill included residents. Findings include: 1. Twelve months of facility evacuation drill documentation was requested. Review of the evacuation drill documentation provided revealed that evacuation drills were conducted for employees on the following dates: January 27, 2023, October 28, 2022 and July 29, 2022. 2. No documentation was available indicating residents participated in the evacuation drills. No other evacuation drill documentation was available for review. 3. During an interview, E1 indicated that all residents were capable of evacuating the facility. 4. During an interview, E1 acknowledged the requested documentation was not available for review.

Based on documentation review and interview, the manager failed to ensure that unless the assisted living center has documentation of having received an exception from the Department before October 1, 2013, a fire alarm system and a sprinkler system is installed according to the National Fire Protection Association 72 and is in working order. Findings include: 1. During an interview, E1 indicated that the facility is equipped with a fire alarm system but is not equipped with sprinkler system. 2. No Fire Safety Evaluation System (FSES) documentation was available for review. 3. During an interview, E1 stated, "My FSES documentation isn't current. I don't know where that is."

Based on observation, documentation review and interview, the manager failed to ensure that two of two pets or animals that were allowed in the facility, were licensed consistent with local ordinances. Findings include: 1. Two dogs were observed inside the facility. 2. Documentation for O1 and O2 failed to reflect that the dogs were licensed consistent with local ordinances. 3. During a telephone interview with the local authority it was determined that the dogs required a license. 4. During an interview, E1 acknowledged that facility documentation failed to indicate the dogs had current licenses.