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Complaint Investigation

Mallard Bay Nursing And Rehab

October 22, 2025 · Cambridge, MD · 520 Glenburn Avenue
Citations 3
CMS Rating 2/5
Beds 160
Provider ID 215191
Healthcare Facility
Mallard Bay Nursing And Rehab
Cambridge, MD  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0604
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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:

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.


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