M&k Assisted Living Layton Lakes LLC

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of two residents sampled. The deficient practice posed a potential illness 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 R1's (admitted 2024) medical record did not include documentation of a completed screening to assess R1's risk of prior exposure to infectious TB and if R1 had signs or symptoms of TB signed or dated by a medical practitioner, as required. Based on R1's date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E2, 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 encouragement to eat meals and snacks, for two of two residents sampled. Findings include: 1. A review of R1’s medical record revealed a service plan, dated August 10, 2025, which revealed R1 required directed care services. However, R1’s service plan did not include encouragement to eat meals and snacks. 2. A review of R2’s medical record revealed a service plan, dated September 11, 2025, which revealed R2 required directed care services. However, R2’s service plan did not include encouragement to eat meals and snacks. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2’s medical record revealed a medication order dated August 8, 2025, for Amlodipine Besylate 5 milligrams (mg), 1 tablet by mouth (po) at bedtime (qhs), hold if systolic blood pressure (SBP) less than 110. 2. A review of R2's medication administration record (MAR) for October 2025 revealed R2 was administered Amlodipine Besylate 5 milligrams at 8:00 PM from October 1, 2025 to present. However, documentation of R2's SBP was not available for review. 3. In an interview, E3 reported R2's vitals were taken every morning; however, vitals were not taken prior to administration of Amlodipine Besylate 5mg. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review, observation, and interview the manager accepted or retained an individual who required restraints, including the use of bedrails. The deficient practice posed a potential for injury. Findings include: 1. A review of R1's medical record revealed a document, dated in April 2024, titled "Determination For Admission." The document revealed R1 required restraints. 2. In an interview, E2 reported that R1 needed restraints to keep R1 in bed because R1 could be aggressive. E2 acknowledged that the manager accepted or retained an individual who required restraints, including the use of bedrails.

Based on documentation review, record review, observation, and interview, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a potential for psychological distress and physical injury. Findings include: 1. R9-10-101.199 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. Review of R1's medical record revealed a service plan for directed care services dated May 8, 2024. This service plan stated "Medical Diagnosis: Agitation, Delirium due to general medical condition". 3. During the facility tour with E2, the Compliance Officer observed R1 lying in bed with one side of the bed pushed up against the wall. A half bedrail was observed attached to the other side of the bed, and an armchair was pushed up against the bed, covering the space not covered by the bedrail. 4. During an interview, E2 reported R1 needed the bedrails to keep R1 in bed as R1 could be aggressive. E2 confirmed that the bed rail and chair were in position to keep R1 in bed. E2 acknowledged R1 was being restrained.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area, and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of Department documentation revealed the facility was authorized to provide directed care services. 2. Review of facility policies and procedures revealed a document titled "Wandering Residents" which stated "Doors will be locked per fire code, alarm/bell or device will be in use to warm [sic] staff that doors are opened." 3. During the facility tour with E2, the Compliance Officer observed two doors leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. One door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not alert caregivers when the door was opened. The other door was not equipped with a device to alert caregivers to the egress of a resident. Both doors were unlocked. 4. In an interview, E2 reported that residents were not supposed to use the door that was not equipped with a device, and that the device on the other door did work, but it was switched off. E2 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

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 Compliance Officer observed the facility's toxicology guide available for use by personnel members was the "Elsevier Toxicology Handbook 2nd Edition" published in 2011. 2. A review of the publisher's website revealed the "Elsevier Toxicology Handbook 4th Edition" was the most recent edition. 3. In an interview, E2 acknowledged that a current toxicology reference guide was not available for use by personnel members.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB. 2. Review of facility policy and procedure documentation for tuberculosis infection control revealed a document titled "Facility TB Risk Assessment Form," however, this form was blank. 3. In an interview, E2 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted.