The Lodge at Mallard's Landing.

WAC 388-78A-2320: The facility failed to ensure that 2 of 9 staff members (Staff B and C) were delegated by a Registered Nurse to administer two types of insulin to a resident. This resulted in residents receiving medications from untrained staff, placing them at risk of harm and health decline. WAC 388-78A-2090: The facility failed to complete safety assessments for the use of medical devices (bed canes and side rails) for 6 of 9 sampled residents. This failure placed residents at risk of physical injury and decreased quality of life. WAC 388-78A-2320: The facility failed to ensure that 13 staff members were delegated by a Registered Nurse to administer medications including oral medications, eye drops, and topical medications to 6 of 6 sampled residents. This failure placed residents at risk of health decline from receiving medications incorrectly by unqualified or untrained staff.

WAC 388-78A-2690: The facility failed to remove a camera recording audio and video in a resident's room prior to notifying and receiving consent from all residents potentially affected by the recording. The facility also failed to post visible signage alerting residents that recording was occurring, violating residents' privacy rights under RCW 9.73.

WAC 388-78A-2210: The assisted living facility failed to ensure a resident received their long-acting insulin (Lantus) as ordered, with the medication running out on 01/21/2024 and not being reordered in time, resulting in only 3 units available instead of the ordered 42 units daily. The resident was without adequate medication for three days, leading to a blood glucose emergency (over 500) and hospital admission for hyperglycemia.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: The Lodge at Mallard's Provider Type: Assisted Living Facility Landing License/Cert.#: 2064 Intake ID: 92699 Compliance Determination #: 28447 Region/Unit #: RCS Region 3 / Unit D Investigator: Michael Goulet Investigation Date(s): 08/22/2023 through 09/18/2023 Complainant Contact Date(s): Allegation(s): 1) Resident not administered vaginal insert medication (Estradiol) by staff, leading to urinary tract infection Investigation Methods: Sample: Total residents: Resident sample size: 5 Closed records sample size: Observations: General environment Resident Condition Residents in their rooms Interviews: Residents Staff Record Reviews: Medication administration records (MAR) Investigation Summary: 1) Per facility staff interview and record review of the named resident's medication administration records (MAR), the resident was not administered Estradiol vaginal insert on four occasions (7/3/23, 7/28/23, 7/31/23 and 8/11/23). One instance was stated (on the resident's MAR) as being related to the medication only being administered by nursing staff, which per remaining records was not factual. Two instances were related to the resident being otherwise predisposed at the scheduled time of administration, but no follow up attempt by staff was noted to have been made. The final instance was related to the medication not being available due to not having been refilled by facility staff. Per facility staff interview, the medication was intended to prevent urinary tract infection (UTI), and staff stated they felt the resident's diagnosis with a was directly related to the missed administration of this medication. Cited per WAC 388-78A-2210 (2) Medication Services Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: The Lodge at Mallard's Provider Type: Assisted Living Facility Landing License/Cert.#: 2064 Intake ID: 93168 Compliance Determination #: 28447 Region/Unit #: RCS Region 3 / Unit D Investigator: Michael Goulet Investigation Date(s): 08/22/2023 through 09/18/2023 Complainant Contact Date(s): Allegation(s): 1) Resident pain medication (Oxycodone liquid) found to have been diverted as evidenced by adulteration of medication (medication removed from bottle and replaced with water). Investigation Methods: Sample: Total residents: Resident sample size: 5 Closed records sample size: Observations: General environment Resident Condition Residents in their rooms Interviews: Residents Staff Record Reviews: Medication administration record (MAR) Investigation Summary: 1) Per facility staff interview, the resident's bottle of liquid Oxycodone (pain reliever) was noted to have been adulterated, as evidenced by a change in the color of the medication and staining to the label indicative of the medication being replaced with water. Per staff and resident interviews, the named resident had not used this medication and no harm was noted. Per staff, the facility has taken steps to secure narcotic medications, and to only receive narcotic medications in the future in tamper resistant and tamper evident packaging. Consultation only per WAC 388-78A-2260 (1) Storing, Securing and Accounting for Medications (evidence available did not rise to level of citation) Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Investigation Summary Report Provider/Facility: The Lodge at Mallard's Provider Type: Assisted Living Facility Landing License/Cert.#: 2064 Intake ID: 93466 Compliance Determination #: 28447 Region/Unit #: RCS Region 3 / Unit D Investigator: Michael Goulet Investigation Date(s): 08/22/2023 through 09/18/2023 Complainant Contact Date(s): Allegation(s): 1) "Hydralazine (blood pressure medication) held numerous times by staff due to wrong education" Investigation Methods: Sample: Total residents: Resident sample size: 5 Closed records sample size: Observations: General environment Resident Condition Residents in their rooms Interviews: Residents Staff Record Reviews: Medication Administration Records (MAR) Investigation Summary: 1) Per record review of the named resident's medication administration records (MAR), there were numerous times when the medication in question (Hydralazine, blood pressure medication) was held by staff in accordance with the physician's orders (hold medication if systolic blood pressure less than 110 or diastolic blood pressure less than 60), but there were also multiple times (8) noted where this medication was held with no blood pressure reading noted. In four cases the medication was noted by staff to be "too close to previous administration" but in these instances administration would have been within appropriate parameters (within 30 minutes of time ordered) for administration. In one case the medication was stated by staff as being "too close to previous administration", but this was noted by staff more than one hour (11:52am) prior to the ordered time of administration (1:00pm), and no re- attempt to administer the medication within the order parameters was noted. In two cases no exception or administration was noted, and in one case the medication was appropriately held due to low diastolic blood pressure, but the blood pressure was not noted on the MAR. Cited per WAC 388-78A-2210 (2) Medication Services . Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . Statement of Deficiencies License #: 2064 Compliance Determination # 28447 Plan of Correction The Lodge at Mallard's Landing Completion Date Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : This requirement was not met as evidenced by: Based on interviews and record reviews, the Assisted Living Facility (ALF) failed to ensure that 3 of 5 residents (Residents 1, 2 and 4) received their medication as ordered. This failure placed these residents at risk of potential harm. Findings Included... During an interview on 08/23/2023 at 11:40am, Facility Administrator (Staff A) stated that Resident 1 (R1) did not receive polyethylene glycol (Miralax, laxative medication) as ordered, and that this led to a bowel blockage requiring hospitalization for the resident on /2023. During an interview on 08/23/2023 at 11:40am, Staff A stated that Resident 2 (R2) did acquire a urinary tract infection (UTI, bladder infection), and that facility staff believed this was a direct result of UTI preventative medication (Estradiol vaginal insert) not being administered by facility staff. During an interview on 08/23/2023 at 11:40am, Staff A stated that Resident 4's (R4) blood pressure medication was held by facility staff when the medication should have been administered to the resident. Record review on 08/24/2023 at 7:00am of R1's Medication Administration Records (MAR) for July and August 2023 showed that R1 did not receive polyethylene glycol/ Miralax on 07/05/2023, 07/06/2023, 07/10/2023 and 07/18/2023 through 08/01/2023 due to this medication being unavailable per staff notation. There was no notation in the MAR of any action taken by staff in order to secure this medication for the resident or that administrative staff had been informed of this non- availability. Record review on 08/24/2023 at 7:00am of R2's Medication Administration Records (MAR) for July and August 2023 showed that R2 missed a total of four doses of their Estradiol vaginal insert medication over this time. One dose on 07/03/2023 was not given due to staff noting incorrectly that only nursing staff could administer this medication, but there was no indication that any nursing staff were contacted regarding this missed dose or that . Statement of Deficiencies License #: 2064 Compliance Determination # 28447 Plan of Correction The Lodge at Mallard's Landing Completion Date any other staff member subsequently administered this dose. One dose on 07/28/2023 and one dose on 07/31/2023 were missed due to the resident being unavailable at the scheduled time of administration (once due to a visitor and once due to a dentist visit), but there was no indication that staff attempted to administer the medication when the resident was available. One dose on 08/11/2023 was missed due to the non-availability of the medication. Record review on 08/24/2023 at 7:00am of R4's Medication Administration Records (MAR) for July and August 2023 showed that R4 missed a total of seven doses of Hydralazine (blood pressure medication) during August 2023. On 08/01/2023 and on 08/20/2023, no medication was administered as scheduled at 1:00pm, with no exception (reason for non-administration) noted, and no resident blood pressure noted (as required per order parameters) to have been taken by facility staff.