Mallard Bay Nursing And Rehab
Inspection Findings
F-Tag F0604
F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated she removed the gait belt from the patient.A typed statement from LPN #6 dated 10/11/25 reported that GNA #5 reported Resident #2 still had a gait belt on for a long period of time. GNA #5 had taken pictures of the incident and they waited for me to get here assuming I was still the supervisor, so I could address the situation. Immediately after hearing what was going on, I went to check on Resident #2 and the belt was gone. She stated that GNA #5 told her she removed the gait belt from Resident #2. I allowed GNA #5 to sit with Resident #2 on 100 unit, her assigned unit because she was available to do so and 200 unit was short aides. LPN # 6 noted she reported it to the [NAME] written Witness statement from the Director of Rehab reported she was notified via text message at 7:12 AM on 10/10/25 by OT #7 that she had seen something on the way out of the building and that ‘it was hidden under his shirt' with a picture of a gait belt around the patient's waist and wheelchair. She added During conversation with OT #7 she stated that the gait belt was hidden under the shirt when she pulled the shirt up.An e-mailed statement from LPN #8 dated 10/13/25 at 4:39 PM reported GNA #5 showed her a picture of Resident #2 with a gait belt while sitting in his wheelchair.During a review of the Facility Reported Incident folder on 10/22/25 at 6:02 AM two additional items were found. These two items included a text message sent at 7:12 AM from OT #7 that showed a picture of a Resident with a belt wrapped around the back of the chair and around the side of the resident. The text stated, Just to let you know, I saw this on my way out. It was 'hidden' under his shirt (Resident #2). The second item was an e-mail dated 10/10/25 at 11:08 AM from the [NAME] President of Clinical Services that stated, Importance: High and Based on the course of events last night, please start in-servicing staff (all nursing staff) regarding restraints and how they are NOT to be used - EVER.During an
interview with the Director of Rehab (DOR) on 10/20/25 at 2:28 PM she reported that OT#7 notified her the next morning at 7:12 AM via text message with a picture of Resident #2 with a belt wrapped around his/her torso and the back of the wheelchair. She confirmed no therapy was provided for Resident #2 on 10/09/25.During an interview with GNA #5 on 10/21/25 at 3:15 PM She reported she went to visit Resident #2, who is far into dementia but she still chats with him/her. She reported she saw the gait belt around his/her waist. It was around the wheelchair and his/her waist, strapped and holding him/her in. I was trying to figure out if he/she had an order and was waiting for the night shift supervisor. She reported she was looking into if the resident had any orders for restraints. and she advised the night shift supervisor when
she came in around 7 PM.During an interview on 10/22/2025 at 6:02 AM with LPN #10 she reported GNA #5 contacted her about Resident #2 and showed her pictures of the torso with a gait belt. She reported GNA #5 said she was going over to tell LPN #6 and then GNA #5 came back. She reported GNA #5 said if
it wasn't taken off by time she went over there she was going to take it off. LPN #10 reported 'there was no face in the pictures, but you could tell it was him/her.During an observation of Resident #2 on 10/22/25 at 7:58 AM he/she was seen sitting in the hallway. The wheelchair he/she was sitting in matches the style of wheelchair in the picture found in the facility incident report. 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab
520 Glenburn Avenue Cambridge, MD 21613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mallard Bay Nursing and Rehab
520 Glenburn Avenue Cambridge, MD 21613
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842
about the resident's care and/or responses to care.
Level of Harm - Minimal harm or potential for actual harm
2) A peripherally inserted central catheter (PICC) line is a thin, flexible tube that is inserted into a vein in the arm or neck and threaded into a large vein in the chest. A PICC line can be used for many types of intravenous treatments.
Residents Affected - Few
On 10/20/25 at 12:01 PM a review of Resident #1's clinical record revealed that the resident was treated for infections with intravenous antibiotics through a PICC line. The record revealed that a PICC line was in place from 06/01/25 and continued to be in place until 10/17/25 when it was discontinued.
Further review of the clinical record revealed a physician's order and a Treatment Administration Record (TAR) as follows: PICC Valved: Flush with 10 Ml normal saline, infuse medication, then 10 Ml normal saline one time a day for PICC MAINTENCE FLUSH PRE AND POSTMED ADMIN -Start Date 06/01/2025 DC Date 10/20/2025. The TAR was signed by Licensed Nurses during the period the resident received antibiotic therapy to indicate that the PCC line was flushed. The TAR and physician's order failed to reveal
the site/location of the PCC line.
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
MALLARD BAY NURSING AND REHAB in CAMBRIDGE, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CAMBRIDGE, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from MALLARD BAY NURSING AND REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.