Signature Healthcare At Mallard Bay

F-F677

3) Review of complaint MD00197499 alleged that the nurse was too busy to change Resident #31's dressing

on the right foot.

On 4/24/25 at 2:19 PM a medical record review was conducted for Resident #31. On 9/24/23 the daughter went to visit Resident #31 who had wounds on the right foot. The date on the dressing stated 9/23/23 with

the initials of Staff #36. The unit manager was informed that the dressing on the foot had not been changed

on 9/23/23 and the unit manager stated they must have put the wrong date on the dressing. The unit manager was informed that Staff #39, the nurse from the previous day stated she did not have the time to change the dressing because she was the only nurse for 40 residents with no medication aid and she requested night shift/evening shift to do the dressing change. There were no notes on 9/24/23 that stated the dressing was changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0725 On 4/30/25 at 11:48 AM Staff #39 was interviewed and stated she was too busy to do the dressing change for Resident #31. Level of Harm - Minimal harm or potential for actual harm 4) On 4/24/25 at 2:46 PM a review of an anonymous complaint alleged the facility needed to be investigated as they were doing illegal things. Residents Affected - Some

A review of the grievance log for November 2024 documented a grievance filed on 11/25/24 for substandard quality of care for Resident #46. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0725 6) On 4/30/25 at 7:09 AM an interview was conducted with Staff #30 who stated, staff was bad about 6 months ago. There were call outs and they tried to get replacements but what can you do for no call no show Level of Harm - Minimal harm or or say they are coming in and don't come. We need a couple of more good aides and nurses in case there potential for actual harm are call outs.

Residents Affected - Some 7) On 4/30/25 at 9:18 AM an interview was conducted with the staffing coordinator. He stated, we can go up above a little bit to 3.1 PPD but we are still not supposed to go over 3.1 PPD. There are some days that are hard to staff. We stopped using agency in August 2024. They gave us a deadline and that's it. There are a lot of days where we can't get an RN at night. Maybe 4 out of 7 nights we don't have an RN.

8) Review of staffing sheets and schedules revealed the facility failed to provide staffing at a level to provide

a minimum of 3.0 hours of bedside care (PPD) per resident per day per state law.

Review of the staffing schedule from 2/14/24 to 3/1/24 documented for 16 of the 17 days reviewed the facility staffing hours were below 3.0 PPD and had the lowest PPD of 2.31 on 2/28/24.

Review of complaint MD00213182 alleged that staff did not get patients up; residents would be soiled for hours; residents did not receive showers. Review of the actual worked nursing schedule for 12/22/24 to 1/3/25 revealed for 9 of 13 days the facility staff hours were below 3.0 PPD and had the lowest PPD of 2.32

on 12/25/24.

Review of the nursing staffing schedule for 2/24/25 to 3/1/25 revealed for 6 of the 6 days the facility staffing hours were below 3.0 PPD and had the lowest PPD of 2.64 on 2/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31145

Residents Affected - Few Based on review of complaints, medical record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 1 (#1) of 42 residents reviewed for complaints during a complaint survey.

The findings include:

1) On 4/23/25 at 2:37 PM a review of complaint MD00216820 alleged that Resident #1 had not received his/her medications as ordered.

Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that included Ankylosing spondylitis (AS), which is a chronic inflammatory disease that primarily affects the spine, causing inflammation and potentially leading to the fusion of vertebrae, resulting in stiffness and reduced flexibility and visual loss.

Review of Resident #1's 4/16 /25 hospital discharge summary documented the medication Biolle Gel Tears Ophthalmic Gel 1%, 1 drop in both eyes was to be administered 3 times a day for dry eyes.

Review of Resident #1's April 2025 Medication Administration Record (MAR) documented the eye drops were not available on 4/17/25, 4/18/25, 4/19/25, 4/20/25, 4/21/25, and 4/22/25.

Nursing notes written on 4/17/25, 4/18/25, and 4/19/25 documented 3 times per day that the drops were unavailable and they were waiting pharmacy delivery. On 4/19/25 a nurse's note wrote that the drops were out of stock. It was after the resident did not receive the drops for 3 days that the Nurse Practitioner was made aware. The nurses continued to document 3 times per day that the drops were unavailable until a note written on 4/22/25 documented, Printed request sent to pharmacy, awaiting arrival and sent printed request to pharmacy to please send medication. The medication was delivered, and Resident received the first dose

on 4/23/25 which was 7 days after admission.

On 4/28/25 at 10:05 AM discussed with the Director of Nursing (DON) the concern related to all medications and their availability from pharmacy. The DON confirmed the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or 31145 potential for actual harm Based on medical record review and staff interview it was determined the facility failed to keep a resident's Residents Affected - Few drug regimen free from unnecessary drugs by failing to monitor the blood pressure prior to administering a blood pressure medication per physician's orders. This was evident for 2 (#7, #21) of 52 residents reviewed

during a complaint survey.

The findings include:

1) On 4/23/25 at 12:05 PM a review of complaint MD00214363 alleged that Resident #7 was not receiving medication as prescribed.

A review of Resident #7's medical record was conducted and revealed a physician's order for Losartan Potassium 50 mg. one time a day for hypertension. The order stated to hold the medication for a SBP (systolic blood pressure) less than 110. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure.

Review of Resident #7's January 2025 Medication Administration Record (MAR) documented that the SBP was not within physician ordered parameters on 1/19/25 and 1/21/25 and the medication was given as evidenced by a check mark and the nurse's initials in the box corresponding to the medication and date. The b/p on 1/19/25 was 104/78 and the b/p on 1/21/25 was 104/68. There were no nursing or emar (electronic) MAR notes that documented the medication was held.

A 1/21/25 at 20:07 PM NP (nurse practitioner) note documented to stop the Losartan secondary to hypotension (low blood pressure) and to monitor the vital signs.

On 4/30/25 at 11:26 AM discussed with the Director of Nursing (DON) who confirmed that the medication should have been held. Discussed that it was given by registered nurses. The DON stated, I will need to do in-services.

2) On 4/24/25 at 8:25 AM a review of Resident #21's medical record was conducted. Review of Resident #21's January, February, March, and April 2025 MAR documented the blood pressure medication Metoprolol Tartrate 25 mg., give 0.5 tablet two times per day. Hold for SBP less than 110 or heart rate less than 60. There was no place next to the medication on the MAR where the blood pressure was documented prior to

the medication being administered.

Review of the vital sign section of the medical record revealed Resident #21's blood pressure was only monitored 5 times out of 62 times the medication was given in January 2025.

Continued review revealed in February 2025 the blood pressure was only monitored 7 times out of 56 times

the medication was given, and the medication was given on 2/11/25 when the blood pressure was 105/70, which was outside of physician ordered parameters. In March 2025 the blood pressure was only monitored 5 times out of 62 times the medication was given and in April 2025 the blood pressure was only monitored 3 times out of 56 times the medication was given up until 4/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0757 On 4/29/25 at 2:00 PM an interview was conducted with Certified Medicine Aide (CMA) #57. CMA #57 stated that she checks the blood pressure, and the system will mark yes when you initial that the meds were given. Level of Harm - Minimal harm or CMA #57 stated she would leave a note and let the nurse know if the blood pressure was outside of potential for actual harm parameters.

Residents Affected - Few On 4/29/25 at 8:53 AM the DON confirmed the issue with the blood pressure parameters and the blood pressure not being documented prior to giving the medication.

On 4/29/25 at 9:44 AM the issue was reviewed with the Medical Director, and he concurred with the surveyor's findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 31145 potential for actual harm Based on medical record review, observation, and interview, it was determined the facility staff failed to Residents Affected - Few provide dental care for a resident with a missing tooth. This was evident for 1 (#17) of 42 residents reviewed for complaints during a complaint survey.

The findings include:

On 4/28/25 at 8:00 AM a review complaint MD00200383 was conducted and alleged that in December 2023 Resident #17 had a missing front tooth, that it could have been a crown or veneer, but it was noticeable.

A review of Resident #17's medical record was conducted. A social service note dated 12/8/23, that was not entered into the medical record until 1/30/24, documented that the social worker received a call from the Ombudsman stating Resident #17's daughter had called to complain, stating that she thought there was a communication problem with the facility. The Ombudsman also stated she received a call from Resident #17's grandson stating Resident #17 had a missing front tooth and apparently the family was not notified.

Further review of Resident #17's medical record failed to produce any further documentation about Resident #17's missing front tooth. Review of the electronic and paper medical record failed to produce documentation that the resident had been seen by a dentist. There were no nutritional assessments found in the medical

record that would have included information about the resident's mouth/teeth status. Resident #17 has been

a resident of the facility since November 2022 and continues to reside in the facility.

On 4/28/25 at 11:50 AM Resident #17 was observed lying in bed. Resident #17 was asked if he/she had a missing front tooth. Resident #17 opened his/her mouth and there was a missing front tooth.

On 4/28/25 at 1:57 PM an interview was conducted with the Medical Director and the Director of Nursing (DON). They were informed that there was no documentation about the missing tooth and there were no nutritional assessments where the teeth would have been evaluated. The Medical Director stated, yes, that concerns me. I expect them to look at weights and any other information in the medical record that is pertinent in the medical record, and I expect them to address them. They should be offered dental services. I feel everyone should be screened and evaluated for dental treatment. If they have teeth that need to be attended to. The Medical Director stated they have quarterly dental assessments and then if a problem is found they should be seen by the dentist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Minimal harm or 34484 potential for actual harm Based on facility record review and interview, it was determined the facility failed to have a full time licensed Residents Affected - Some Nursing Home Administrator (NHA) authorized by the State of Maryland from 11/9/22 until 11/15/23 and 2/4/24 until 3/4/24. This is being cited as past noncompliance since the facility currently has had a licensed administrator in place that was verified by the Surveyor on 4/24/25.

The findings include:

On 4/24/25 the Surveyor asked the Administrator to provide a timeline of the NHAs for the facility since November 2022 to investigate an anonymous complaint the facility had been operating without a full time licensed Nursing Home Administrator.

Review of the timeline list of the facility's NHAs provided by the current Administrator on 4/24/25 revealed Staff #46 was the Administrator 11/9/22-1/1/23, Staff #47 was the Administrator 12/12/22-6/30/23, Staff #48 was the Administrator 7/3/23-9/29/23, Staff #49 was the Administrator 11/15/23-2/4/24, Staff #50 was the Administrator 3/4/24-8/18/24, and Staff #1, the current Administrator, has been at the facility since 8/19/24.

During interview with the Administrator on 4/24/25 at 2:10 PM the Surveyor reviewed the list provided by the Administrator advised the Administrator the Surveyor could not verify Staff #46, #47 and #48 had NHA license in Maryland.

During interview with the Administrator on 4/24/25 at 2:20 PM, the Administrator confirmed the facility did not have a licensed Nursing Home Administrator authorized by the State of Maryland from 11/9/22 until 11/15/23 and again from 2/4/24 until 3/4/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0840 Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34484

Residents Affected - Few Based on medical record review and interview, the facility staff failed to obtain outside services for a resident

in a timely manner (Resident #12). This was evident for 1 of 52 residents reviewed during a complaint survey.

The findings include:

Review of Resident #12's medical record on 4/23/25 the Resident was admitted to the facility in June 2024 and was readmitted to the facility on [DATE REDACTED] following a hospitalization with a diagnosis to include infection and inflammatory reaction due to internal joint prosthesis.

Review of the Resident's hospital discharge summary revealed the Resident needs a follow up with Infectious Disease physician. Further review of the medical record revealed the Resident has not been seen by the Infectious Disease physician or has an appointment scheduled.

Interview with the Director of Nursing on 4/30/25 at 9:40 AM confirmed the facility staff failed to schedule an appointment for Resident #12 to see the Infectious Disease physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 34484

Residents Affected - Few Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #30). This was evident for 1 of 52 residents reviewed during a complaint survey.

The findings include.

A medical record is the official documentation of a healthcare organization. As such, it must be maintained in

a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.

Review of Resident #30's medical record on 4/23/25 revealed the Resident was admitted to the facility 6/10/23 to following orthopedic surgery for rehabilitation and was discharged from the facility on 6/29/23.

During interview with Resident #30's representative (RP) on 4/23/25 at 1:38 PM, the RP stated he/she received a call from the facility on the morning of 6/29/23 that the Resident had fallen and they were sending him/her to the hospital. The RP stated he/she would like to have more information regarding the Resident's fall.

Further review of the Resident's medical record revealed the last nurse's note and evaluation prior to the Resident's fall on 6/29/23 was on 6/28/23 at 4:41 PM. The only nurse's note on 6/29/23 was at 10:50 AM that states the Resident's RP called stating the Resident was being transferred to shock trauma.

Interview with the Director of Nursing on 4/25/25 at 11:40 AM confirmed the facility staff failed to maintain a complete medical record for Resident #30 to include nurse's notes, assessments and discharge information related to the Resident's fall on 6/29/23 and transfer to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 31145 potential for actual harm Based on staff interview, it was determined the facility failed to obtain a full-time social worker when the Residents Affected - Some certified number of beds exceeded 120 in the facility. Currently the facility was licensed for 160 certified beds. This was evident for 1 out of 1 required personnel and had the potential to affect all residents.

The findings include:

On 4/23/25 at 10:06 AM Staff 4, the Social Work Assistant was interviewed and stated she had been employed at the facility for almost 3 weeks and was full-time. Staff #4 stated, we do not have a full-time social worker here. Staff #4 described her duties and stated, I have a check off list that I have to do. The assistant is here to help the Director.

Staff #4 stated she had an administration degree for the medical front and back desk and was a certified medical assistant and had a certification in activities. Staff #4 stated she was previously an activities director. Staff #4 stated she was trained by the Regional Social Services Director and that the Regional Director was always on call.

On 4/24/25 at 2:50 PM an interview was conducted with the interim Nursing Home Administrator (NHA). The NHA confirmed Staff #4 was not a licensed certified social worker and the facility did not currently have a full time qualified social worker on staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 50 215191

F-F692

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31145

Residents Affected - Some Based on review of complaints, documentation review, and interview, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 16 of 42 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff interviews, and

review of staffing schedules. This deficient practice had the potential to affect all residents.

The findings include:

1) Sixteen out of forty-two complaints that the Office of Health Care Quality (OHCQ) received and reviewed

on this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) not having enough time to give resident showers and toilet and change residents.

2) Five of the 16 complaints were related to residents not receiving showers.

a) On 4/23/25 at 3:55 PM a review of complaint MD00206200 alleged the facility was short staffed and residents were laying in their urine and feces and not receiving proper care.

On 4/24/25 at 10:10 AM an interview was conducted with Resident #16 who stated that there was not enough staff and that showers were not being given and that he/she has not had a shower in a year. Resident #16 stated he/she has only had bed baths. Resident #16 stated, I never refuse a shower.

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

F-F791

3b) A continued review of Resident #17's medical record revealed on 2/3/25 that the resident had a documented weight of 183.8 pounds (lbs.). There was no weight in March 2025. A weight was taken on 4/1/25, 4/2/25, and 4/3/25, which was documented as 166.6 lbs. which was a 17.2 lb. weight loss which was

a 9.4 % weight loss.

There was no documentation found in the medical record that the dietician, physician, and responsible party were notified.

On 4/28/25 at 12:26 PM an interview was conducted with LPN #22. LPN #22 was asked about the weight process, and she stated, the GNAs (geriatric nursing assistants) weigh and the nurse puts the weight in the system. The Director of Nursing is then alerted. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 50 215191 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0580 On 4/28/25 at 1:57 PM an interview was conducted with the Medical Director and the DON. They both stated

they would have expected to be notified about the weight loss. Level of Harm - Minimal harm or potential for actual harm Cross Reference