SILVER CREEK INN MEMORY CARE COMMUNITY

<p><span style="font-size: 12pt;">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.</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">Findings include:</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">1.</span><span style="font-size: 7pt;">     </span><span style="font-size: 12pt;">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."</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">2.</span><span style="font-size: 7pt;">     </span><span style="font-size: 12pt;">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."</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">3.</span><span style="font-size: 7pt;">     </span><span style="font-size: 12pt;">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.</span></p><p><span style="font-size: 12pt;"> </span></p><p><span style="font-size: 12pt;">4.</span><span style="font-size: 7pt;">     </span><span style="font-size: 12pt;"> In an interview, E1 acknowledged that R1 was restrained in the shower by E2. </span></p><p><span style="font-size: 12pt;"> </span></p>

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.

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if an employee was unable to assist a resident in an emergency.

Findings include:

1. A review of facility documentation revealed a fall prevention and fall recovery training program was not available for review.

2. A review of E1's, E2's, E3's, E4's, E5's, and E6's personnel records revealed documentation of fall prevention and recovery training was not available for review.

3. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

This is a repeat citation from the complaint inspection conducted on September 13, 2022.

Based on documentation review, record review, and interview, the owner failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411, for two of six employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card."

2. A review of E2's and E3's personnel records revealed documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) was not available for review.

3. In an interview, E1 acknowledged documentation of compliance with A.R.S. \'a7 36-411(C)(1)-(2) for E2 and E3 was not available for review.

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 Board), for two of three sampled caregivers.

Findings include:

1. A review of facility documentation revealed a staffing schedule dated July 2023. The schedule indicated E2 was scheduled to work from 6:00 AM to 2:00 PM on July 1, 2, 4, 5, and 8-10, 2023.

2. A review of facility documentation revealed a staffing schedule dated March 2023. The schedule indcated E4 was scheduled to work from 2:00 PM to 10:00 PM on March 1, 2, and 6-15, 2023.

3. A review of E2's and E4's personnel records revealed documentation of completion of a caregiver training program approved by the Department or the NCIA Board was not available for review.

4. In an interview, E1 reported the personnel records for E2 and E4 had previously gone missing and did not contain all required documentation. E1 acknowledged E2 and E4 both worked as caregivers at the facility and had not provided documentation of completion of a caregiver training program approved by the Department or the NCIA Board.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver received orientation specific to the duties to be performed by the caregiver before providing assisted living services to a resident, for one of three caregivers sampled. The deficient practice posed a risk if the employee was unable to meet a resident's needs.

Findings include:

1. A review of E3's personnel record revealed E3 was hired as a caregiver. E3's personnel record revealed no documentation indicating E3 received orientation specific to the duties to be performed by a caregiver.

2. A review of the facility's policies and procedures revealed a policy titled "Personnel requirements policy". The policy contained a section titled "Orientation" which stated: "...New staff will begin orientation on the first day of hire to be included with new hire packet...to consist of in service videos including infecion control..."

3. In an interview, E1 acknowledged E3's personnel record did not include documentation indicating E3 received orientation specific to the duties to be performed by a caregiver.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services to a resident, for two of three caregivers sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Job Description" reviewed and signed by E1 on March 23, 2023. The policy stated: "All caregiving staff must possess a current CPR/First aid certificate and update as needed."

2. A review of the facility's policies and procedures revealed a policy titled "Personel Requirements" reviewed and signed by E1 on March 23, 2023. The policy stated: "Positions requiring a valid cardiopulmonary resuscitation and first aid certification will need to complete the class in-person to demonstrate the individual's ability to perform CPR and First aid...if the renewal time-frame lapses, the employee will be suspended from employment."

3. A review of E2's personnel record revealed E2 worked as a caregiver. E2's personnel record did not contain documentation of current CPR and first aid training certification.

4. A review of E4's personnel record revealed E4 worked as a caregiver. E4's personnel record did not contain documentation of current CPR and first aid training certification.

5. A review of facility documentation revealed a staffing schedule dated July 2023. The schedule indicated E2 was scheduled to work from 6:00 AM to 2:00 PM on July 1, 2, 4, 5, and 8-10, 2023.

6. A review of facility documentation revealed a staffing schedule dated March 2023. The schedule indcated E4 was scheduled to work from 2:00 PM to 10:00 PM on March 1, 2, and 6-15, 2023.

7. In an interview, E1 acknowledged E2's and E4's personnel records did not contain documentation of current CPR and first aid training certification.

This is a repeat citation from the complaint inspection conducted on September 13, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided assistance with activities of daily living according to the resident's service plan, for three of four residents sampled.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-101(5) states "Activities of daily living" means "ambulating, bathing, toileting, grooming, eating, and getting in or out of a bed or a chair."

2. A review of R2's medical record revealed a service plan dated in June 2023 for directed care services. The service plan contained a section titled "Bathing" which stated R2 was to receive full assistance with showering "2x/week" and a section titled "Dental" which stated R2 was to receive assistance "2x daily."

3. A review of R2's medical record revealed a document titled "Resident assistant record" dated July 2023. The document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." The document included sections for shifts "NOCS", "Days", and "EVES". However, there was no documentation indicating services were provided on July 1, 2023 on the "Days" shift, July 2, 2023 on the "NOCS" and "EVES" shifts, July 7, 2023 on the "NOCS" shift, July 8, 2023 on the "NOCS" shift, July 9, 2023 on the "EVES" shift, and July 10, 2023 on the "Days" shift.

4. A review of R3's medical record revealed a service plan dated in June 2023 for directed care services. The service plan contained a section titled "Bathing" which stated R3 was to receive full assistance with showering "2x/week" and a section titled "Dental" which stated R3 was to receive assistance "2x daily."

5. A review of R3's medical record revealed a document titled "Resident assistant record" dated July 2023. The document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." The document included sections for shifts "NOCS", "Days", and "EVES". However, there was no documentation indicating services were provided on July 1, 2023 on the "Days" shift, July 2, 2023 on the "NOCS" and "EVES" shifts, July 3, 2023 on the "Days" and "EVES" shift, July 6, 2023 on the "NOCS" shift, July 8, 2023 on the "Days" and "EVES" shifts, and July 9, 2023 on the "EVES" shift.

6. A review of R4's medical record revealed a service plan dated in June 2023 for directed care services. The service plan contained a section titled "Bathing" which stated R4 was to receive full assistance with showering "2x/week" and a section titled "Dental" which stated R4 was to receive assistance "2x daily."

7. A review of R4's medical record revealed a document titled "Resident assistant record" dated July 2023. The document stated "I certify that I have read and provided care for this resident this shift as stated on the nursing care directions." The document included sections for shifts "NOCS", "Days", and "EVES". However, there was no documentation indicating services were provided on July 1, 2023 on the "Days" shift, July 2, 2023 on the "NOCS" and "EVES" shifts, July 7, 2023 on the "NOCS" shift, July 8, 2023 on the "NOCS" shift, and July 10, 2023 on the "Days" shift.

8. In an interview, E1 acknowledged the aforementioned services were not provided according to the frequencies specified in the service plans.