Mallard Creek Therapy and Living Center

In the surveyor’s words

From the most serious findings on record at Mallard Creek Therapy and Living Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to store, label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, on 1 medication carts (hall 400 Nurses cart) and 1 medication room of 4 medication carts and 1 medication room reviewed for pharmacy services. The facility failed to ensure proper storage of acidophilus 1 billion (supplements used to support gut health and maintain a healthy balance of bacteria in the digestive tract) which required refrigeration per manufacturer's guidelines. […]

• No harm, potential for more than minimal, patternF812Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure an opened bottle of barbecue sauce was properly refrigerated after use in accordance with manufacturer instructions. The facility failed to ensure food items stored in the freezer were properly labeled with the contents after being removed from the original packages and dated to reflect when the food items were opened. The facility failed to ensure food packages stored in the freezer were properly sealed and secured. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2026

  Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident#18, Resident#50, Resident#55), reviewed for infection control. 1.The facility failed to ensure MA C sanitized the blood pressure cuffs between (Resident#18, Resident#50, Resident#55), to prevent the spread of infections. 2.The facility failed to ensure a hospice aide transported clean linen by methods that ensure cleanliness. These failures could place residents at risk for healthcare associated cross contamination and infections. Findings include:Resident #18's1. […]

• No harm, potential for more than minimal, isolatedF689Jul 2, 2026

  Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Day Room) out of 1 Day Room reviewed for accidents and hazards. The facility failed to ensure that 1 of 1 mechanical lift in the Day Room was locked, secured, and stored in a secure designated area when not in use. This failure could place residents, visitors and staff at risk of falls and/or injuries.Findings included: Observation of the facility's Day Room (a common area for residents to gather) on 07/01/26 at 8:43AM revealed a mechanical lift stored toward the entrance of the room, with the breaks unlocked. One resident was observed attempting to go into the Day Room at that time. […]

• No harm, potential for more than minimal, isolatedF695Jul 2, 2026

  Based on observations, interviews, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for two (Resident #16 and Resident #47) of five residents reviewed for respiratory care. 1.) The facility failed to ensure that Resident #16's nebulizer mouthpiece was bagged in a plastic bag and stored in a drawer, which was consistent with professional standards. 2.) The facility failed to ensure that Resident #47's nebulizer mouthpiece was bagged in a plastic bag and stored in a drawer, which was consistent with professional standards. […]