Mallard Bay Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Mallard Bay Nursing and Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Mar 30, 2026

  Based on interviews and record reviews, it was determined that the facility failed to ensure its Infection Preventionist met the mandatory qualifications for the position.The findings include:An Infection Preventionist (IP) is responsible for the facility's Infection Prevention and Control Program. This position requires specialized training in infection control.On 3/24/26 at 10 AM, during an interview with the Director of Nursing (DON), confirmed she/he was the Infection Preventionist for the facility. The DON reported that she/he hasn't completed specialized training in infection control and the facilities staff has no one else who is currently qualified for the position. […]

• No harm, potential for more than minimal, patternF628Aug 28, 2026

  Based on interviews and record reviews, it was determined that the facility failed to; notify the resident's responsible party in writing, of the reason for a resident's transfer, to provide the resident and/or resident's responsible party with the bed-hold policy, and to notify the local ombudsman's office of a resident's transfer/discharge. This was evident for 4 (#103, #106, #11, #2) out of 4 residents reviewed for hospitalizations during the facility's annual recertification survey.Findings include: 1. A medical record review was conducted for resident # 103 on 8/25/26 at approximately 10:35 AM and upon review it revealed the resident was sent to the hospital on 6/1/26 for unresponsiveness. […]

• No harm, potential for more than minimal, patternF584Jun 25, 2026

  Based on review of complaint 3027850, observations, and interviews conducted during a complaint survey, it was determined that the facility failed to provide maintenance services necessary to maintain resident rooms and equipment. This issue affected 5 of 12 residents reviewed (#8, #9, #10, #11, #12) and 3 of 3 nursing units observed.The findings include: On 6/24/26 at 9:00 AM a review of complaint 3027850 was conducted regarding environmental concerns. On 6/24/26 at 10:05 AM the following observations were made during environmental walking rounds: Resident Wheelchairs in Disrepair: Damage or missing components (including torn vinyl covering, missing foam padding, and missing armrests) were noted on wheelchairs for Residents #8, #9, #10, #11, and #12. […]

• No harm, potential for more than minimal, patternF692Jun 25, 2026

  Based on medical record review and interview, it was determined the facility staff failed to assess and monitor residents' nutrition needs and intervene in a timely manner. This was evident for 3 (Resident #3, #6 and #4) of 5 residents reviewed during a complaint survey. The findings include: 1) Review of Complaint 3040167 was conducted on 6/24/26 regarding Resident #3's care at the facility. Review of Resident #3's medical record on 6/24/26 revealed the Resident was admitted to the facility in 2023 with a diagnosis to include dysphagia. Dysphagia is the medical term for difficulty swallowing. Further review of Resident's medical record revealed on 2/16/26 the Resident was seen and assessed by Nurse Practitioner (NP) #17 for weight loss. […]

• No harm, potential for more than minimal, patternF761Mar 30, 2026

  Based on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that resident medications and supplies, including oxygen were maintained in a secure fashion. This was an observation on 2 occasions and 2 additional times after the implementation of education by the facility DON and occurred on 3 of 3 units.The findings include:On 3/23/26 at 10:50 AM an oxygen tank was observed sitting on the floor with no supporting device present. […]