Mallard Bay Nursing And Rehab
MALLARD BAY NURSING AND REHAB in CAMBRIDGE, MD — inspection on April 30, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the grievance investigation revealed a witness statement from Staff #9 that documented that on the morning of 11/25/24 at 8:10 AM Staff #54 went to Staff #9's office and stated that Resident #46 was visibly upset this morning when she entered the resident's room and disclosed to her that he/she was left sitting in a soiled brief from 10:30 PM until 8:00 AM when Staff #54 entered the room.
A witness statement for an interview conducted with Staff #55 revealed that evening was the first night ever having Resident #46 or the unit and she said she didn't know the resident.
Staff #55 stated that she and the other GNA, Staff #30, took the entire unit together.
Staff #55 could not remember how many rounds she did during the night and stated that she did not answer any call bells.
A witness statement for an interview conducted with Staff #30, she stated that her and Staff #55 worked together on the unit and that Staff #30 did not answer any call bells for Resident #46.
Staff #30 was asked if she changed Resident #46 or completed a round on the resident at any time in the shift, Staff #30 stated that Staff #55 handled that end of the hall and they met up at room [ROOM NUMBER] and proceeded to do care together on other rooms.
On 4/24/25 at 3:05 PM Staff #31 was interviewed and stated Resident #46 was total care.
Staff #31 stated Resident #46 rang the bell and was extremely upset, crying and said night shift didn't change him/her.
Staff #31 stated 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.
Staff #31 was asked if they were short staffed and his response was, on a regular day I have 8 to 12 patients.
When there are call outs I can get up to 16 people on day shift.
Sometimes there are 2 GNAs (geriatric nursing assistants) for 30-40 residents. We can't give showers and serve 3 meals on day shift plus do documentation.
On 4/24/25 at 3:15 PM Staff #32 was interviewed and stated she normally has 12 residents on day shift.
She said she would have 14 to 15 residents if they only had 3 GNAs. We can't get showers done when we work like that.
On 4/24/25 at 4:00 PM Staff #9 was interviewed and that, the GNAs did not change the resident.
There were 2 GNAs and they split the floor and they team worked it. 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.
5) On 4/29/25 at 4:36 PM Staff #58 stated, Corporate always had control of staffing.
215191
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 215191 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab 520 Glenburn Avenue Cambridge, MD 21613
Review of geriatric nursing assistant (GNA) activities of daily living (ADL) documentation for showers for May 2024 documented the resident did not receive any showers for the month. Resident #16 received bed baths on 15 of the 31 days in May.
Further review of GNA ADL documentation for February 2025, March 2025, and April 2025 documented Resident #16's missed showers or was not offered.
Cross Reference
The surveyor asked LPN #22 who notified the dietician, and her response was, I don't know who is notifying the dietician. Do we have one.
215191
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 215191 B.
Wing 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab 520 Glenburn Avenue Cambridge, MD 21613