AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box … · AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 98907, Lakewood, WA 98496 Licensee: One Mallards Landing, LLC From: DSHS,

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATIONPO Box 98907, Lakewood, WA 98496

May 7, 2018

RE: The Lodge at Mallard's Landing License #2064

Dear Administrator:

The Department completed a follow-up inspection of your assisted living facility on May2, 2018 for the deficiency or deficiencies cited in the report/s dated March 8, 2018 andfound no deficiencies.

The Department staff who did the follow-up inspection:

One Mallards Landing, LLCThe Lodge at Mallard's Landing7083 Wagner WayGig Harbor, WA 98335

Michael Goulet, Complaint Investigator

Sincerely,

Lisa Cramer, Field ManagerRegion 3, Unit AResidential Care Services

If you have any questions please, contact me at (253) 983-3826.

Residential Care Services Investigation Summary Report

Provider/Facility: The Lodge at Mallard's Landing(688431)

Intake ID(s): 3495880

License/Cert. #: AL2064Investigator: Goulet, Michael Region/Unit: RCS Region 3/Unit A Investigation

Date(s):03/01/201803/08/2018

through

Complainant Contact Date(s):Allegations:1) One male resident has been hitting female residents.

2) One resident moved to memory care unit without assessment or care plan.

3) Resident to resident altercation not reported to CRU.

4) Facility staff not credentialed.

5) One female resident not showered for one and a half weeks after admission.

Investigation Methods:Sample: 3 of 3 residents, no

named residentsObservations: General environment

Residents in their roomsStaff to residentinteractionsCleanliness/ grooming ofresidents

Interviews: StaffResidentsPersons not associatedwith the facility

Record Reviews: Care planAssessmentChange in condition formProgress notesEmployee qualifications(6)Staff listPersonnel Qualificationsreport

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Residential Care Services Investigation Summary Report

Allegation Summary:1, 3) Per interview with residents and staff and review of staff progress notes, there was no indication that the male resident(Resident #2) had physical altercations with female residents, but it was noted that this resident had physical altercations withboth his roommate and with facility staff. Per staff interview and record review of progress notes, this resident had beeninvolved in a physical altercation with his roommate which led to injury, and there was no indication per staff or record reviewthat this incident had been reported to the department. Failed facility practice substantiated.

2) Per interview with staff and record review of the resident's (Resident #1) care plan, assessment and care plan addendum andchange in condition form, the resident did have a care plan and assessment prior to transfer from the assisted living side of thefacility to the memory care unit. Per interview with the resident's son, the resident did have orders from her primary careprovider to move to memory care prior to transfer.

4) Record review of the credentials and qualifications for memory care unit staff, documented that one of six staff (Staff D) didnot have a current HCA certification and had been working in the facility for 255 days as of the date this was discovered. Thislack of certification was supported by interview with facility DNS who removed the caregiver in question from the work scheduleat the time this was made known. Failed facility practice substantiated.

5) Per observation of named residents and several other residents in the facility, all were noted to be clean and well groomedand no areas of the facility (including resident rooms and common areas) were unclean, and no odor of feces or urine waspresent at any time during visits to the facility.

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

388-78A-2630 (1b) Reporting abuse and neglect388-78A-2474 (4)Training and Home Care Aid certification

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Completion DateLicense #: 2064

March 8, 2018

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The Lodge at Mallard‘s Landing

Statement of Deficiencies

Plan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATIONPO Box 98907, Lakewood, WA 98496

Licensee: One Mallards Landing, LLC

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 3, Unit A

PO Box 98907

Lakewood, WA 98496

(253)983-3826

As a result of the on-site complaint investigation the department found that you are not in

compliance with the licensing laws and regulations as stated in the cited deficiencies in the

enclosed report.

You are required to be in compliance at all times with all licensing laws and regulations to

maintain your assisted living facility license.

Michael Goulet, Complaint Investigator

I understand that to maintain an assisted living facility license I must be in compliance with all

the licensing laws and regulations at all times.

This document references the following complaint number: 3495880

The department staff that inspected and investigated the assisted living facility:

The department has completed data collection for the unannounced on-site complaint

investigation on 3/1/2018 and 3/5/2018 of:


7083 Wagner Way

Gig Harbor, WA 98335

The following sample was selected for review during the unannounced on-site complaint

investigation : 3 of 22 current residents and 0 former residents.

Residential Care Services Date

DateAdministrator (or Representative)


March 8, 2018

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Plan of Correction


WAC 388-78A-2474 Training and home care aide certification requirements.

(4) The assisted living facility must ensure all persons listed in subsection (2) of this section,

obtain the home-care aide certification.

Based on interview and record review, one of six staff (Staff D) in the Assisted Living Facility

(ALF) Memory Care Unit had not received Home Care Aid (HCA) certification within 200 days

of date of hire as required. This failure placed all residents in the facility at risk of not receiving

appropriate care and services. Findings include:

Record review of facility staff qualifications on 3/5/2018 documented that Staff D did not have a

current HCA certification. Staff D had been working in the facility since 6/23/2017, a total of

255 days.

During an interview on 3/5/2018, facility Director of Nursing Services (Staff E) stated that Staff

D had not completed her HCA certification per his own review of computer staff records and

that Staff D would be removed from the work schedule until this requirement was met.

Plan/Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active

measures to correct this deficiency. By taking this action, The Lodge at Mallard's

Landing is or will be in compliance with this law and / or regulation on

(Date)________________ . In addition, I will implement a system to monitor and

ensure continued compliance with this requirement.

I understand that to maintain an assisted living facility license, the facility must be in

compliance with the licensing laws and regulations at all times.

Administrator (or Representative) Date

This requirement was not met as evidenced by:

WAC 388-78A-2630 Reporting abuse and neglect.

(1) The assisted living facility must ensure that each staff person:

(b) Makes an immediate report to the appropriate law enforcement agency and the department

consistent with chapter 74.34 RCW of all incidents of suspected sexual abuse or physical abuse

of a resident.

Based on interview and record review, a resident to resident altercation between two of two

residents (Resident #2 and Resident #3) leading to injury was not reported to the department as

required. This failure placed both residents at risk for further physical and psychological harm.

Findings include:

This requirement was not met as evidenced by:


March 8, 2018

3Page 3of



Plan of Correction


During an interview on 3/5/2018, Staff C stated that on 1/30/2018 Resident #2 had attacked his

roommate (Resident #3) on a couch in a common area of the facility.

Record review of facility progress notes from 1/30/18 documented that Resident #2 had gotten

on top of Resident #3 and hit this resident in the face. Injuries to Resident #2 requiring

bandaging were noted, but there was no indication that the department had been notified of this

incident.

Plan/Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active

measures to correct this deficiency. By taking this action, The Lodge at Mallard's

Landing is or will be in compliance with this law and / or regulation on

(Date)________________ . In addition, I will implement a system to monitor and

ensure continued compliance with this requirement.

I understand that to maintain an assisted living facility license, the facility must be in

compliance with the licensing laws and regulations at all times.

Administrator (or Representative) Date

Residential Care ServicesInvestigation Summary Report (Amended #1)

Provider/Facility: The Lodge at Mallard's Landing(688431)

Intake ID(s): 3471783, 3477116

License/Cert. #: AL2064Investigator: Goulet, Michael Region/Unit: RCS Region 3/Unit A Investigation

Date(s):12/21/201702/05/2018

through

Complainant Contact Date(s): 02/07/2018, 12/21/2017Allegations:1) Night shift staff do not answer phone calls2) Resident not transported to hospital for evaluation of fall 12/3/20173) Staff not following care plan on checking on residents4) Staff not escorting residents to activities as per care plan5) Residents not receiving medications as ordered6) Resident sunburned after being informed not to leave resident outside7) Staff work 16 hours per day, six days per week8) Resident did not receive medication for the first week of stay (August 2014)9) One resident called 911 due to staff refusing to answer phone10) Camera installed in resident's room by resident's daughter who monitors and harasses staff to perform actions which areagainst the resident's wishes

Investigation Methods:Sample: five of five residents,

including named residentObservations: General environment

Residents in their roomsStaff to residentinteractionsMed passes bymedication techs

Interviews: ResidentsStaffFacility ownerPersons not associatedwith the facility

Record Reviews: -MedicationAdministration Records-TreatmentAdministration Records-Admission Agreement-FacilityProcedure/protocol foranswering phones afterbusiness hours

Page 1 of 4


-Resident Care Plan-Letter from facility tofamily member-Email from facility tofamily member-Photo taken by familymember of resident'sarms

Allegation Summary:1) Per interview with facility executive director (ED) and per record review of the facility, protocol for answering phones afterbusiness hours (after 6:00pm), staff are to transfer calls to the nursing station (Wellness staff) wireless phone which night shiftstaff keep with them. Per complainant, the phone was not answered on two occasions (10/19/17 and 12/3/2017) when thecomplainant was concerned for the safety of her family member. Per interview with another resident, staff did not answer eitherthe resident's call pendant or the facility phone after the resident fell in his bathroom, leading to the resident calling 911 forassistance. 2) Per facility Resident Care Coordinator, there was no record of the resident having fallen on 12/3/2017. Therewould have been a care conference initiated if the resident had fallen, but this did not take place and no injury had been notedfor the resident at this time. Per record review of the resident's chart, there is no progress note reference to any fall occurring onthis date. Unable to substantiate. 3,4) Per staff interviews and per record reviews of Medication Administration Records,Treatment Administration Records and resident Care Plan, the resident is being checked on as required and being escorted toactivities as ordered. There were times noted when the resident declined to go to activities and these are noted in the records aswell. Per staff interview, the resident is cognitively intact enough to understand her own wishes and the

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Unalleged Violation(s):(continued) resident does not want to go to bed at a specified time or does not want to be escorted to dining or activities, then itis not appropriate for staff to force the resident to do so. Unable to substantiate failed practice related to this allegation. 5) Perinterviews with the two residents who were stated by the complainant as having not received medications as ordered, one is notadministered medications by facility staff, (self administers his own medications) and stated that he has never missed anymedications due to any failure by facility staff, and the second stated that she had missed a medication dose once due to beingout of the facility for dinner (this incident was already investigated by RCS and no failed practice identified). They did not feelthere was any problem with the facility's medication administration process. 6) Per complainant, the facility Resident CareDirector (RCD) had been informed not to let the resident out in the sun due to photo toxicity related to recent antibioticprescription, but per interview with the RCD, this information was never communicated to her or any staff at the facility. Perrecord review of the resident's chart, there is no notation of this precaution. Per record review of photo provided by complainant,there is a noted color change to the resident's forearms, but no indication of blistering or injury. Per interview, the residentstated that she does sunburn easily. Unable to substantiate failed facility practice in relation to this allegation. 7) Per interviewwith staff who was named as having worked 16 hours per day, 6 days per week, this allegation is not true, and no staff haveworked this schedule at the facility. This was corroborated by other staff interviews at the facility. 8) Per interview with staff atthe resident's pharmacy, the medical orders for the resident's medication were not received at the pharmacy until 8/18/2014.Per record review of the resident's Medication Administration Record from August, 2014, the resident began to receivemedications from the facility on the same date (8/18/2014). Per record review of facility communication to the pharmacy, thepharmacy was informed by the facility of the resident's impending admission on /2014, two days prior to the facilityadmission date of /2014 (records from the resident's chart). Per the pharmacist there was no indication as to why themedications were not ordered until 8/18/2014. No information substantiates failed practice in relation to this allegation. 9) Perinterview with resident, the resident pushed his call button after falling between the toilet and the wall in his bathroom and thenwhen staff did not immediately respond, the resident stated that he called 911. The resident stated that Emergency MedicalServices personnel did not respond to the facility because as he was talking to the 911 operator Staff did come into the roomand assist the resident. The resident was unable to state how long

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

(Continued) this process took. Unable to substantiate failed practice related to this allegation.10) Per interviews with staff, staff are uncomfortable going into the resident's room due to the presence of a camera in theroom, and the resident has been noted to be agitated when staff repeatedly request she do things such as go to bed when shedoes not want to. Per interview, the resident stated she is not aware that a camera is in her room and stated she does not haveissues related to staff requests. Per interview with the resident's husband, there is no thought that the presence of a camera inthe resident's room constitutes any violation of the resident's rights. Per interviews with facility staff, they have been aware ofthe camera's presence in the resident's room for some time, but the resident has never been assessed for this device todetermine if this is appropriate. No ongoing evaluation of the need or appropriateness of this device has been determined by

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facility staff. Cited per WAC 388-78A-2690 (3a, b) Electronic Monitoring Equipment.Staff not answering phones after business hours per facility policy on multiple occasions cited per 388-78A-2700 (1) SafetyMeasures.

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Documents

AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box … · AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 98907, Lakewood, WA 98496 Licensee: One Mallards Landing, LLC From: DSHS,