Mallard Bay Nursing And Rehab
MALLARD BAY NURSING AND REHAB in CAMBRIDGE, MD — inspection on October 22, 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
During an interview with [NAME], VP of Clinical Services on 10/21/25 at 11:25 AM she reported she came in the next day after the incident and started interviewing people to find out what happened.
Ultimately, disciplinary action was taken on four employees because they knew about the gait belt wrapped around the resident and didn't take any action.
She reported she couldn't find out who did it.
She was shown a copy of the picture texted by OT #7 from the Facility Reported Incident folder that showed the torso of Resident #2 with the gaitbelt wrapped around him/her and the wheelchair.
During an interview with the DON on 10/22/2025 at 7:18 AM she reported it was an unfortunate event that happened, no one is fessing up and we don't know who did it.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab
520 Glenburn Avenue Cambridge, MD 21613
SUMMARY STATEMENT OF DEFICIENCIES
Based on medical record reviews and interviews, it was determined the facility failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents.
This was evident for 1 (Residents # 1) of 1 resident reviewed during the complaint survey.The findings include:Resident #1 was readmitted to the facility in May 2025 with diagnoses which include Systemic Lupus Erythematosus and Rheumatoid ArthritisOn 10/20/25 at 12:01 PM the surveyor reviewed Resident #1's clinical record.
The review revealed that the resident received intravenous antibiotics for infections on several occasions.
The most recent were Vancomycin via a peripherally inserted central catheter (PICC) line for several days from June 2025 to October 2025, Daptomycin via PICC line from August 2025 to September 2025 and Amoxicillin -Pot Clavulanate by mouth in October 2025.Further review of the clinical record failed to reveal a Care Plan with interventions for antibiotic therapy and PICC line care while the resident was receiving treatment for infections.
During an interview on 10/21/25 at 8:50 AM the Unit Manager LPN#3 reviewed Resident #1's care plans and confirmed the surveyor's findings.
The Unit Manager stated that it was the practice of the facility to update the resident's care plan in keeping with the residents' condition and clinical treatments, but she did not give a reason as to why Residet#1's care plan was not updated.In an interview on 10/21/25 at 9:25 AM the Director of Nursing was informed of the surveyor's findings.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab
520 Glenburn Avenue Cambridge, MD 21613
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/21/25 at 8:50 AM with the Unit Manager LPN# 3, the surveyor enquired as to where the PICC line was located.
The Unit Manager reviewed Resident#1's clinical record and told the surveyor that she did not know because it was not stated on the physician's order or on the TAR.
Unit Manager LPN #3 also stated that it was the practice for the site of the PICC line to be documented in the physician's order and on the TAR.
During an interview on 10/21/25 at 9:25AM the Director of Nursing (DON) confirmed the surveyor's findings by reviewing the records.
The DON stated, we do document the site but it is not documented on this record.
On 10/22/25 at 7:37 AM the DON informed the surveyor that the Assistant Director of Nursing had completed an audit and PICC line orders were updated to include the location of the catheter site.
Facility ID: