Mallard Bay Nursing: Dietitian Skips Diabetic Resident - MD

The resident, identified in inspection records only as Resident 16, arrived at the facility with an A1C of 11.5 percent. A1C measures average blood sugar over two to three months; normal is below 5.7 percent. The hospital that discharged the resident had recommended a carbohydrate-controlled diet. Mallard Bay put the resident on a regular diet instead.

Nobody caught the error for a week. It wasn't a dietitian review that flagged it. The resident asked for larger portions on March 17, and the diet order was changed then. By March 25, when an inspector arrived in response to a complaint, the dietitian still had not seen the resident or reviewed the medical record.

The inspector went to the resident's room that afternoon. The resident said they were "very frustrated with the meals." Asked whether a dietitian had visited, the resident said no.

The dietitian, interviewed the same day, explained her triage system. Residents on tube feedings come first. A diabetic patient admitted for blood sugar management, eating regular food with no carbohydrate controls for the first week of their stay, would not have been a priority. She acknowledged Resident 16 "should have been admitted on the recommended diet from the hospital." She also said Resident 16's weight was stable, then paused when the inspector pointed out the resident had been weighed exactly once in two weeks. Physicians had been documenting the weight as stable on their visit notes throughout.

Twelve hours a week is not much time to cover an entire nursing home's dietary needs. The dietitian said she relies partly on risk meetings to learn which residents need to be seen.

The problems extended well beyond Resident 16. Resident 26 had been readmitted to the facility in the fall and flagged for a significant weight loss of 6.4 pounds over 30 days. The dietitian saw the resident in September 2025 and documented it. Then nothing. No follow-up visit, no documented intervention. By March 25, Resident 26 weighed 22 pounds less than at that September review. The loss continued for six months without a dietitian assessment.

Resident 27 had been admitted at the end of February 2026 with a diagnosis that included severe protein-calorie malnutrition. A month passed. The dietitian had not seen the resident as of March 25. In that time, according to the facility's own weight records, Resident 27 lost 14 pounds in approximately two weeks, a 7 percent drop that meets the clinical threshold for significant weight loss. No dietitian assessment had been completed.

Three residents. One admitted for diabetes. One losing weight for six months unchecked. One admitted with severe malnutrition and losing more weight inside the facility. None seen by the dietitian when the inspector arrived.

The inspector reviewed the findings with the director of nursing that afternoon, then sat down with the facility's medical director, administrator, director of nursing, and a corporate vice president of clinical services at 3:30 p.m. on March 25. The inspection report describes the meeting as a review of "concerns related to the lack of dietitian coverage and inability to timely see all the admissions and other residents."

The dietitian's position was not in dispute. She said plainly that 12 hours a week required her to make choices about who she could reach. Resident 16, frustrated and eating the wrong diet for a week, had not made the cut.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Mallard Bay Nursing and Rehab from 2026-03-30 including all violations, facility responses, and corrective action plans.

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