Salter Springs Assisted Living LLC

Based on observation, documentation review, 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 the resident’s health and safety. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed an unlocked cabinet containing resident medications. The cabinet was located in a laundry room. The Compliance Officer observed that the door leading into the laundry room was also unlocked. The cabinet contained a variety of medications in bags and boxes, including Metoprolol, Amlodipine, Cephalexin, Sertraline, Lorazepam, Olanzapine, Pantoprazole, Albuterol Sulfate, Oxybutynin, and numerous other medications. 2. A review of the facility’s policies and procedures revealed a policy titled, “Medication and Medication Services Policies and Procedures” which stated the following: · “The policy for storing medications is that the facility will store medications for residents in a locked area. · The procedures for discarding medications are: a. When a resident has terminated residency or the mediations have expired, medications purchased by the resident’s representative or family, [sic] will be offered back to the resident’s representative or family and as follows: 1) If the family refuses to accept the medications, the medications will be returned to the pharmacy where the medications were purchased; 2) If the medications are not able to be returned to the pharmacy or it is impractical to return medications, the facility will dispose of the medications; 3) The facility will dispose of the medications by mixing the medications with hydrogen peroxide and kitty litter. The mixture of medications, hydrogen peroxide and kitty litter will be bagged and put in the trash. If kitty litter and hydrogen peroxide are not available, the medications will be placed in water until they are partially dissolved, then bagged and place [sic] in the trash; 4) Disposal of medications will be documented on the Medication Disposal Log and signed and dated by the person disposing of the medications and whenever possible, signed and dated by a witness.” 2. In an interview, E1 reported the medications were stored in the laundry room for disposal. E1 also reported the laundry room door was always locked. 3. In the exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review and interview, after the manager had a reasonable basis, according to Arizona Revised Statutes (A.R.S.) § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation, initiate an investigation of the alleged abuse, neglect, or exploitation, and maintain documentation including all requirements of this rule for at least 12 months after the date the investigation was initiated. The deficient practice posed a risk if a resident was not protected from abuse, neglect, or exploitation. Findings include: 1. In an interview, E1 reported being aware of an incident involving R1 on March 18, 2025. E1 stated that on the morning of the incident, R1 had a hospice nurse give R1 a bed bath. The hospice nurse observed bruises on R1's chest and arms, and the nurse mentioned it to the caregivers. The caregivers checked up on R1 and saw the bruises. The caregiver contacted the manager, but the incident was not reported in compliance with A.R.S. § 46-454. 2. A review of facility incident reports revealed a report created for the incident involving R1 on March 18, 2025. However, the report did not indicate that the manager or any other employee reported the suspected abuse according to A.R.S. § 46-454. 3. In an interview, E1 acknowledged the incident was not reported as required.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed ambulatory residents. 2. The Compliance Officer observed toxic materials stored in an unlocked cabinet located in a bedroom. This cabinet did not have a locking mechanism and was accessible to residents. The following toxic materials that were observed: - Disinfecting wipes; - A bottle of Pine-Sol multi surface cleaner; - A bottle of Great Value Toilet Bowl Cleaner; and - A spray bottle of Odoban disinfectant. 3. In an interview, E1 acknowledged the toxic materials listed above were not locked and were accessible to residents.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when initially developed and when updated, signed and dated by the resident's representative, for one of two residents sampled. The deficient practice posed a risk if the resident's representative was unaware of the services to be provided to the resident at the facility. Findings include: 1. A review of R2's medical record revealed a written service plan dated June 30, 2023 for directed care services. However, the service plan was not signed and dated by R2's representative. 2. In an interview, E1 acknowledged R2's service plan was not signed and dated by R2's representative.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 30, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed a signed medication order dated May 10, 2023. This medication order stated "Lantus 100IU/ML injection give 15IU at bedtime". 3. Review of R2's medical record revealed a July 2023 medication administration record (MAR). This MAR stated the following: "Lantus 100 IU/ML injection 15IU daily". However, the MAR did not contain an initial for who administered the medication for: July 1, 2023; July 2, 2023; and July 3, 2023. 4. During an observation of R2's medications, Lantus was observed. 5. During an interview, E2 reported the blood sugar meter was broken and medication was not administered on the aforementioned dates. E2 acknowledged medication was not administered in compliance with a medication order.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency, or injury, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. Findings include: 1. A review of R1's medical record revealed a medication administration record that identified R1 in the hospital. Upon further research, E2 reported R1 experienced an elevated heart rate on July July 10, 2023 so 911 was called. R1 was transported to the hospital. 2. The Compliance Officer requested to review the documentation of the incidents involving R1. However, documentation was not provided for review. 3. In an interview, E1 and E2 acknowledged the required information was not documented for this incident.