CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Mallard Bay Nursing and Rehab
View the most recent health deficiencies and inspection results for Mallard Bay Nursing and Rehab. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Mallard Bay Nursing and Rehab. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2026-01-08 | 2026-02-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2026-01-08 | 2026-02-17 | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-01-08 | 2026-02-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2026-01-08 | 2026-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2026-01-08 | 2026-02-17 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2026-01-08 | 2026-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-01-08 | 2026-02-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-01-08 | 2026-02-17 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2026-01-08 | 2026-02-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-01-08 | 2026-02-17 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-09-05 | 2026-01-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-10-22 | 2025-12-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-10-22 | 2025-12-03 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2025-10-22 | 2025-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-09-05 | 2025-10-15 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2025-09-05 | 2025-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-09-05 | 2025-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-09-05 | 2025-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-09-05 | 2025-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-09-05 | 2025-10-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-09-05 | 2025-10-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2025-09-05 | 2025-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-09-05 | 2025-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-09-05 | 2025-10-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-09-05 | 2025-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-30 | 2025-06-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2025-04-30 | 2025-06-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2025-04-30 | 2025-06-11 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2025-04-30 | 2025-06-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-04-30 | 2025-06-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-04-30 | 2025-06-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-04-30 | 2025-06-11 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2025-04-30 | 2025-06-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2025-04-30 | 2025-06-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-04-30 | 2025-06-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-04-30 | 2025-06-11 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-04-30 | 2025-06-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-04-30 | 2025-06-11 | Y |
| Provide or obtain dental services for each resident. | Health | 2025-04-30 | 2025-06-11 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2025-04-30 | 2025-06-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-04-30 | 2025-06-11 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2025-04-30 | 2025-06-11 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2025-04-30 | 2023-11-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-26 | 2022-10-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-26 | 2022-10-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-26 | 2022-10-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-26 | 2022-10-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-08-26 | 2022-10-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-26 | 2022-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-26 | 2022-10-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Meet other general requirements. | Fire Safety | 2018-12-04 | 2019-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-04 | 2019-01-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-04 | 2019-01-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-04 | 2019-01-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-04 | 2019-01-11 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-04 | 2019-01-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-04 | 2019-01-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-04 | 2019-01-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-12-04 | 2019-01-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-12-04 | 2019-01-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-12-04 | 2019-01-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-04 | 2019-01-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-04 | 2019-01-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-12-04 | 2019-01-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-04 | 2019-01-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-04 | 2019-01-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-12-04 | 2019-01-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2026-03-30 | Not Fixed | Y |
| Respond appropriately to all alleged violations. | Health | 2026-03-30 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-03-30 | Not Fixed | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2026-03-30 | Not Fixed | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2026-03-30 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2026-03-30 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-03-30 | Not Fixed | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2026-03-30 | Not Fixed | Y |