A list of the most recent deficiencies for Mallard Bay Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
| 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 |
| 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 |
| 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 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-26 | 2022-10-26 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-18 | 2022-10-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-18 | 2022-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-18 | 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 | 2022-08-18 | 2022-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-18 | 2022-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-18 | 2022-10-20 | N |
| Meet other general requirements. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-15 | 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 | 2019-01-15 | 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 | 2019-01-15 | 2019-04-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-15 | 2019-04-05 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | 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 |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-04 | 2019-01-11 | 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2018-12-04 | 2019-01-11 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-08-04 | 2017-09-11 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-08-04 | 2017-09-11 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-04 | 2017-09-11 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-04 | 2017-09-11 | N |
| Give or get x-rays and other tests in a timely manner to meet the needs of residents. | Health | 2017-08-04 | 2017-09-11 | 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 | 2017-08-04 | 2017-09-11 | 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 | 2017-08-04 | 2017-09-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-04 | 2017-09-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-08-04 | 2017-09-11 | N |
