Mallard Bay Nursing: Falsified TB Test Records - MD

That finding emerged during a complaint survey that inspectors completed March 30, 2026. It was one of three residents whose medical records contained documentation problems serious enough to flag.

The TB test entry is the starkest of the three. When inspectors reviewed the medication administration record for Resident 16, they found a notation for March 18 that read "9," a code directing staff to see a corresponding nurse's note. There was no nurse's note. For the read date, March 20, staff had written "negative," recording a result for a test that was never given.

When an inspector met with Resident 16 in his or her room on March 25, the resident said directly: they never received the PPD injection.

The director of nursing confirmed it. She told the inspector that the facility was out of PPD solution on March 18, so "no," they would not have administered the test. She said they would do it now.

Nobody explained how a result got recorded for a procedure that didn't happen.

The second finding involved a resident whose wound care had generated a complaint before inspectors ever arrived. Resident 7 had raised concerns about staff not changing bandages. When inspectors checked the medication administration records for the dates the resident had complained about, the records showed staff had signed off on completing the treatments.

The resident, sitting in a face-to-face meeting with the inspector and the director of nursing on March 25, said it had happened again just that past weekend.

The inspector left the room and pulled the MAR for additional dates. What came back was different from what the earlier review had shown. For March 18 and March 23, staff had not signed off on wound care at all. There were also three days out of 24 where no one had documented the application of A&D ointment to the resident's feet.

The records that existed said care was given. The records that were missing said otherwise. Resident 7's complaint, it turned out, had something to it.

The third case involved Resident 2, who had a bruise on the left hand, described in facility documentation as an injury of unknown origin. A nursing assistant noticed it and told a nurse. A change-in-condition report was started at 11:30 in the morning on January 8.

The pain assessment wasn't completed until 9:11 that night, nearly ten hours later.

Resident 2 had scored a zero on a standardized cognitive assessment completed in December 2025, the lowest possible score, indicating severe impairment. The resident could not explain how the injury happened and could not use a standard pain scale to communicate whether anything hurt. The inspector's concern, reviewed with the director of nursing at the exit conference, was that a cognitively impaired resident with an unexplained injury went most of a day without a completed pain evaluation.

The inspection report classified all three findings under a single deficiency: failure to maintain complete and accurate medical records. The level of harm was listed as minimal harm or potential for actual harm.

That classification covers a wide range. A falsified test result is not the same thing as a late signature. But they ended up in the same category, on the same form, reviewed at the same exit conference, with the same director of nursing who said she would speak to staff.

Resident 7, whose bandages were or weren't being changed depending on which part of the record you looked at, was still in the building when inspectors left.

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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