Mallard Bay Nursing: Medication Security Failures - MD
That was March 25. Five days later, inspectors found another unsecured medication sitting on top of a treatment cart.
A complaint inspection at Mallard Bay Nursing and Rehab, completed March 30, 2026, found that staff repeatedly left resident medications and medical supplies accessible and unsecured — on open carts, on countertops, in hallways where other residents rolled past in power wheelchairs. The problem showed up on all three units in the facility. It persisted after staff were educated about it. It persisted while senior leadership was physically present and watching.
The first finding came on March 23 at 10:50 in the morning. An oxygen tank was sitting on the floor behind the bed of Resident 12, on unit 1, with nothing holding it upright. An unsecured oxygen tank is a fall and fire hazard. RN #1 was told about it and immediately retrieved a tank holder and secured it.
Two days later, at 7:31 in the morning on unit 3, a tube of Collagenase Santyl cream sat on top of a treatment cart. The cream was labeled for Resident 17. Two residents in power wheelchairs rolled past the cart as it sat there. Staff were at the nursing station nearby. RN #7, when told about it, said whoever had received the delivery hadn't put it away and secured it on the spot.
The director of nursing learned about both findings at 8:10 that same morning and said she would put education in place immediately.
The education happened. Then, at 1:53 that afternoon, the inspector returned to tour the facility alongside the director of nursing, the nursing home administrator, and the corporate vice president of clinical services. All four of them walked up to the unit 2 nursing station at the same moment and found an unlocked, unattended treatment cart waiting for them. The corporate VP locked it.
On March 30, the final day of the inspection, Diclofenac gel prescribed for Resident 19 was found on top of a treatment cart alongside multiple packs of dressings. The director of nursing happened to walk past two minutes later and was told about it.
Four separate observations. Three units. One round of staff education that changed nothing by that same afternoon.
The inspection report classified the harm level as minimal or potential, with some residents affected. That classification reflects the absence of a documented injury, not the absence of risk. Diclofenac is a prescription anti-inflammatory. Collagenase Santyl is a prescription enzyme used to treat wounds. Neither belongs within reach of a resident who might mistake it for something else, or a visitor, or anyone passing through a hallway. Unsecured oxygen tanks can tip, rupture a valve, and become projectiles.
What the inspection captures, more than any single item left on a cart, is what happened when the facility tried to fix the problem. The director of nursing promised education. The education was delivered. And within hours, on a tour that included the director of nursing herself, the inspector found another unlocked cart. Nobody on that tour had caught it before the inspector did.
Mallard Bay Nursing and Rehab operates at 520 Glenburn Avenue in Cambridge, on Maryland's Eastern Shore. The inspection was a complaint survey, meaning someone had already raised concerns before the inspector walked through the door.
Resident 19's Diclofenac sat on that cart on the last morning of the inspection. The director of nursing walked past and was told about it. What happened to the medication after that, the report does not say.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 6, 2026 · Our methodology
MALLARD BAY NURSING AND REHAB in CAMBRIDGE, MD was cited for violations during a health inspection on March 30, 2026.
Five days later, inspectors found another unsecured medication sitting on top of a treatment cart.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.