The Lodge at Mallard's Landing

Extension cord used as permanent wiring in the 2nd floor staff lounge.

Facility failed to provide an inventory of fire-resistance-rated construction and failed to conduct/maintain records of annual inspections.

Fire block foam used is designed for residential/non-rated construction only; incorrect firestop system used.

Missing documentation for annual flow testing and 5-year FDC hydro testing; bent sprinkler head in cooler; blocked heads in garage.

Kitchen suppression pull station blocked by storage boxes.

Fire extinguishers blocked by storage boxes and a cart.

Unable to provide documentation showing resident room smoke alarms have been tested.

Kitchen CO2 cylinders not secured.

Fire alarm circuit breaker in main electrical room missing required lock device.

Multiple fire-rated door deficiencies found; facility requires audit.

No annual forward flow testing or 5-year hydro testing performed.

Failed to conduct twelve planned/unannounced fire drills; missing drills for specific shifts in Q2, Q3, and Q4 2024.

Facility failed to ensure 2 of 9 staff members were delegated by an RN to administer insulin to a resident, resulting in untrained staff administering medications.

The licensee failed to ensure two staff were delegated by an RN to administer two types of insulin to one resident. Resulted in untrained staff administering medications, putting resident at risk of harm.

Facility failed to remove a camera in a resident's room that was recording audio and video without obtaining proper consent from all affected residents and without posting required notification signage outside the room.

The facility failed to ensure a resident received ordered insulin for three days due to failure to re-order medication, leading to elevated blood glucose levels and hospitalization. Staff also documented inaccurate administration records.

Narcotic liquid medication (Oxycodone) for one resident was found to have a portion removed and replaced with water. No harm resulted. Evidence did not rise to the level of a citation.

Facility failed to ensure 3 of 5 residents received medications as ordered: R1 did not receive laxatives leading to bowel blockage; R2 missed estrogen inserts leading to UTI; R4's blood pressure medication was withheld without proper protocol.

Decorative trees found blocking corridor electrical panels on floors 2 and 3.

Unapproved penetration repair in mechanical room corridor wall near apartment 101; unprotected floor penetration around network cabling in second floor phone/cable room.

Various door issues: sagging stairwell and nurses office doors; loose handle on apartment 334; unapproved door stopper on laundry door; propped open fire doors in cinema and laundry rooms.

Missing required 'FIRE DOOR—KEEP CLOSED' signage on cinema and laundry room doors.

Memory care kitchen fire door failed to self-close and latch.

No documentation provided for fire/smoke damper inspection/testing in past 4 years.

No documentation provided for dry sprinkler system full flow trip testing in past 3 years.

Facility must perform a heat serval for the kitchen hood to determine required fusible link rating.

Memory care staff lack keys to unlock fire extinguisher cabinets.

Smoke detector in main soiled laundry room was hanging from ceiling wiring.

Memory care courtyard gate latch installed above maximum 48-inch height.

Padlock found on memory care courtyard exit gate; staff unaware of key location for emergency egress.