The November incident at Mallard Bay Nursing and Rehab illustrates the human cost of chronic understaffing that has plagued the facility for months. Federal inspectors found the facility repeatedly failed to meet Maryland's minimum requirement of 3.0 hours of bedside care per resident per day.
Staff member #31 discovered the resident on the morning of November 25, 2024. "Resident #46 rang the bell and was extremely upset, crying and said night shift didn't change him," the aide told inspectors. "Resident #46 was wet and the bed was soaked with all urine. Resident #46 was laying in it and it was way more urine that it should have been."
The two overnight aides, Staff #55 and Staff #30, worked together but divided the unit between them. Staff #55 told investigators it was her first night with that resident and "she didn't know the resident." She couldn't remember how many rounds she completed and "did not answer any call bells."
Staff #30 said she also didn't answer any call bells for the resident and that Staff #55 "handled that end of the hall."
The staffing crisis extends far beyond that single night. Review of schedules from February 2024 through March 2025 revealed systematic understaffing. During a 17-day period in February and March 2024, the facility fell below state requirements 16 days, hitting a low of 2.31 hours per resident per day on February 28.
During the Christmas and New Year period of 2024-2025, inspectors found staffing below 3.0 hours on 9 of 13 days reviewed, with Christmas Day hitting just 2.32 hours per resident.
"On a regular day I have 8 to 12 patients," Staff #31 told inspectors. "When there are call outs I can get up to 16 people on day shift. Sometimes there are 2 GNAs for 30-40 residents. We can't give showers and serve 3 meals on day shift plus do documentation."
Another aide, Staff #32, said she normally handles 12 residents but gets 14 to 15 when only three aides work. "We can't get showers done when we work like that."
The facility's staffing coordinator acknowledged the problem during an April 30 interview. "There are some days that are hard to staff," he said. "There are a lot of days where we can't get an RN at night. Maybe 4 out of 7 nights we don't have an RN."
The facility stopped using agency staff in August 2024 after corporate "gave us a deadline and that's it," according to the coordinator.
Staff #9, who no longer works at the facility, was blunt about management's response to the crisis: "I no longer work there because they were unwilling to correct the staffing issues. They would know we were short and they would not be willing to staff with more people and they knew it was bad."
Beyond staffing, inspectors found medication failures that put residents at risk. A resident with ankylosing spondylitis and visual loss went seven days without prescribed eye drops after admission from the hospital. Nurses documented daily that the drops were unavailable, but didn't notify the nurse practitioner until the third day.
Blood pressure medications were administered without required monitoring. One resident received blood pressure medicine on two occasions when their systolic pressure was 104, below the physician's order to hold the medication if pressure dropped below 110.
Another resident received blood pressure medication 231 times over four months, but staff only checked blood pressure beforehand 20 times.
The facility also operated without a licensed nursing home administrator for extended periods. From November 9, 2022 until November 15, 2023, and again from February 4, 2024 until March 4, 2024, no licensed administrator was in place.
A resident who lost a front tooth in December 2023 never received dental care despite family complaints to the ombudsman. When inspectors observed the resident in April 2025, the tooth was still missing. The medical director told investigators: "I feel everyone should be screened and evaluated for dental treatment."
Staff #58 pointed to corporate control as the root of staffing problems: "Corporate always had control of staffing."
The facility's 160 certified beds require a full-time licensed social worker under federal regulations, but inspectors found only a social work assistant with an administration degree and medical assistant certification handling social services duties.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mallard Bay Nursing and Rehab from 2025-04-30 including all violations, facility responses, and corrective action plans.
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