Mallard Bay Nursing and Rehab

Inspectors wroteBased on review of complaint 3027850, observations, and interviews conducted during a complaint survey, it was determined that the facility failed to provide maintenance services necessary to maintain resident rooms and equipment. This issue affected 5 of 12 residents reviewed (#8, #9, #10, #11, #12) and 3 of 3 nursing units observed.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to assess and monitor residents' nutrition needs and intervene in a timely manner. This was evident for 3 (Resident #3, #6 and #4) of 5 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, review of facility reported incident 3015069, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 1 (Resident#1) of 4 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on review of a complaint, record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of a resident. This was evident for 1 (Resident #6) of 5 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to report two injuries of unknown origin to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 (Resident #3) of 7 residents reviewed during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review and interviews, it was determined the facility staff failed to 1) notify the Resident's case manager of discharge location and 2) ensure home health services were set up for a resident at time of discharge. This was evident for 1 (Resident #5) of 3 residents reviewed for discharge during a complaint survey.

Inspectors wroteBased on review of a complaint, medical record review and interviews, it was determined the facility staff failed to include the discharge instructions and prescriptions in the resident's medical record. This was evident for 1 (Resident #5) of 3 residents reviewed for discharge during a complaint survey.

Inspectors wroteBased on medical record review and interviews, it was determined the facility failed to administer medications as ordered (Resident #2) and failed to administer wound treatments as ordered (Resident #6). This was evident for 2 of 7 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interviews it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers as ordered for a resident. This was evident for 1 (Resident #3) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure its Infection Preventionist met the mandatory qualifications for the position.

Inspectors wroteBased on observation during tour and interview with facility staff, it was determined that the facility staff failed to ensure that resident medications and supplies, including oxygen were maintained in a secure fashion. This was an observation on 2 occasions and 2 additional times after the implementation of education by the facility DON and occurred on 3 of 3 units.

Inspectors wroteBased on the review of a complaint related to a new admission diet, staff and resident interviews, and medical record review, it was determined that the facility failed to employ sufficient staff to ensure all residents with dietary concerns were met. This was evident during the review of 3 of 3 (Resident #16, #26, #27) residents related to complaints about diet.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to thoroughly investigate allegations related to potential abuse and injuries of unknown origin. This was evident during the review of 2 of 8 facility reported incidents (Residents #3).

Inspectors wroteBased on a complaint related to the oral status of residents with tracheostomies and percutaneous endoscopic gastrostomy (PEG) tubes, observations, interviews with residents and staff, it was determined that the facility failed to provide oral care to a resident that was dependent on staff for activities of daily living (ADL). This was evident during the review of a complaint for 1 of 3 (#23) residents related to quality of care.

Inspectors wroteBased on medical record review, observation and interview with facility staff, it was determined that the facility staff failed to ensure that the residents' medical records were maintained and documentation was complete. This was evident for 3 of 22 (#2, #7 and #16) medical records reviewed during a complaint survey.

Inspectors wroteBased on observations and interviews and medical record review, it was determined that the facility failed to ensure infection control orders were followed and consistent throughout the facility. This was evident during the review of a complaint related to residents on transmission-based precautions.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to 1) ensure Minimum Data Set (MDS) assessments were accurately coded and 2) complete a discharge assessment. This was evident for 5 (#1, #6, #2, #5, #7 ) of 10 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice (Residents #1, #2 and #3). This was evident for 3 of 10 residents reviewed during a complaint survey.1. The facility staff failed to administer medications as ordered by the physician for Resident #3. A review of Resident #3's medical record was conducted on 1/6/26 for the Resident's complaints of not receiving medications as ordered in December 2025. Review of Resident #3's November and December 2025 Medication Administration Records (MAR) revealed: On 11/28/25 the Resident was ordered Triamcinolone Acetonide Mouth/Throat Paste, apply to left lower side of gum topically after meals and at bedtime for mouth ulcer for 7 days. The Resident was not administered Triamcinolone Acetonide until 12/1/25. [...]

Inspectors wroteBased on medical record review, observation, and interview, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 2 (#1, #6) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on observation and interview, it was determined that facility staff failed to ensure that resident medical records remained private and confidential. This was evident for 1 of 3 nursing units observed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to document the details of a transfer of a resident (Resident #9). This was evident for 1 of 3 residents reviewed for transfers during a complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to follow-up when the Nurse Practitioner documented that a resident needed glasses due to not being able to see properly. This was evident for 1 (Resident #1) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on record review, observation, and interview, it was determined the facility staff failed to ensure fall mats and the resident's call bell were properly in place for a resident with a history of falls. This was evident for 1 (#6) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (#5) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain outside services for a resident per the hospital discharge summary in a timely manner. This was evident for 1 (#2) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased 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. This was evident for 2 (#1, #2) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to maintain an environment free of physical restraints. This was evident for 1 (Resident #2) of 1 resident reviewed for restraint usage during a complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record reviews and interviews, it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 2 (Resident #3 and #1) of 4 residents reviewed for accurate medical record documentation during the complaint survey.

Inspectors wroteBased on observation and resident interview, the facility failed to ensure that a resident's dignity was maintained for 1 of 3 residents reviewed for privacy during observation rounds and failed to ensure that staff wore facility-issued identification badges while providing resident care. This was evident for 5 staff observed during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that resident's rooms were properly maintained and their environment was homelike. This was found to be evident for 2 resident rooms observed on the 100 hallway during the facility's survey.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents were free from misappropriation of property when Registered Nurse (RN) #25 misappropriated Resident #76's prescribed oxycodone following discharge from the facility. This deficient practice was evident for 1 Resident (#76) reviewed for medications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that allegations of misappropriation of resident (#76) property were reported to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 resident.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to follow the resident careplan to ensure ongoing communication between the dialysis center and the facility for continuity of care for a resident receiving dialysis services. This was found to be evident for 1 (Resident # 93) of 3 residents reviewed for dialysis during the facility's survey.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that services provided met professional standards of quality by not maintaining accountability and proper destruction of controlled substances, resulting in the misappropriation of Resident #76's prescribed oxycodone. This deficient practice involved 1 resident (#76) reviewed.

Inspectors wroteBased on observations, record review, and staff and resident interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #59) out of 40 residents reviewed during the survey.

Inspectors wroteBased on observations, record review, and resident and staff interviews, it was determined that the facility failed to ensure that a resident received their assistive devices to maintain vision. This was evident for 1 (Resident #7) out of 1 resident reviewed for hearing and vision services during the survey.

Inspectors wroteBased on medical record review and interviews with the resident and facility staff it was determined the facility failed to ensure that a wheelchair used for transporting residents had leg lifts in place prior to transport. This was found to be evident for 1 (Resident # 19) of 40 residents reviewed during the survey.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident records were complete and accurate when the Assistant Director of Nursing (ADON) falsified resident (#12's) weights; failed to include the indication for use of an anticoagulant medication (Xarelto) on the Medication Administration Record (MAR) and Physician Order Sheet (POS) for one resident (#80) and failed to document a change in condition for a resident (#59). This occurred for 3 of 40 residents reviewed during the survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to ensure that infection control guidelines were being followed. This was found to be evident for 1 of 3 units toured and during medication administration observations for the survey.

Inspectors wroteBased on observations, medical record review, and interview, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed and failed to position a resident comfortably in a chair. This was evident for 6 (#9, #3, #44, #40, #45, #29) residents observed on 2 of 3 nursing units during a random tour during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to notify a resident's physician and/or representative for a change in condition. This was evident for 4 (#6, #5, #17, #21) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 4 (#9, #19, #18, #17) of 13 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 7 (#18, #21, #40,#19, #17, #20, #39) residents of 13 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 (#5, #3, #46, #40, #7, #21) of 52 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on complaint, record review, and interview, it was determined the facility failed to have documentation that residents were offered and/or received a shower on the resident's assigned shower day. This was evident for 6 (#16, #27, #52, #50, #51, #41) of 52 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health. This was evident for 8 (#6, #11, #12, #30, #37, #42, #1, #5) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to do quarterly nutrition assessments for residents and failed to recognize a resident's weight loss and notify the physician and dietician. This was evident for 3 (#15, #17, #21) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on facility record review and interview, it was determined the facility failed to have a full time licensed 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.

Inspectors wroteBased on staff interview, it was determined the facility failed to obtain a full-time social worker when the 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.

Inspectors wroteBased on medical record review and interview, the facility staff failed to respect a resident's privacy (Resident #8). This was evident for 1 of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation, medical record, and staff interview, it was determined the facility failed to ensure that a resident was free from neglect when the facility failed to provide the required services to meet the needs of the resident. This was evident for 1 (#46) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews and failed to complete MDS assessments timely. This was evident for 1 (#18) of 52 residents reviewed for assessment reviews during a complaint survey. The findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents' progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. The Minimum Data Set (MDS) assessments are an integral part of RAI and include completion of standardized assessment questions. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, it was determined that facility staff failed to develop a comprehensive, resident centered care plan for nutrition. This was evident for 1 (#17) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to have quarterly care plan meetings for residents and failed to update a care plan after a change in condition. This was evident for 3 (#12, #3, #17) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and incident review of wound care, the facility failed to change a wound dressing. This was evident for 1 (#31) out of 7 residents.

Inspectors wroteBased on interview and record review, it was determined the facility failed to keep a resident with decreased cognition from exiting the building unsupervised. This was evident for 1 (#47) of 52 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure a physician supervised the care of a resident, as evidenced by the physician failing to evaluate a resident's weight loss. This was evident for 2 (#17, #21) residents reviewed for 42 complaints reviewed during a complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's 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.

Inspectors wroteBased on medical record review, observation, and interview, it was determined the facility staff failed to 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to notify a resident's physician when a treatment plan had changed (Resident #187). This was evident for 1 out of 59 residents reviewed during an annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined the facility staff failed to provide written notice for emergency transfers to the Ombudsman. This was found to be evident for 1 out of 1 (#71) resident reviewed for a facility-initiated transfer during the investigation of the survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #14 and #70). This is evident for 2 of 6 residents reviewed for pressure ulcers during the annual survey.

Inspectors wroteBased on a review of the medical record and interview with staff it was determined that the facility failed to ensure that the physician addressed a resident's significant weight gain. This was evident for 1 (#51) of 7 residents reviewed for weight gain or loss during the annual survey.

Inspectors wroteBased on observation, interview and review of medical record, the facility staff failed to serve meals as requested by residents (Resident #33 and #62). This was evident for 2 out of 24 residents reviewed for dining during an annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for preventive health care immunization for Residents (#25, #51, and #73). This was evident for 3 of 5 residents selected for review of immunizations during the annual survey.

Inspectors wroteBased on review of staff records and interview with facility staff, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) received a performance review in 2018. This was true for all nursing aids who were eligible for a performance review in 2018. Failure to perform performance reviews prevents the facility from providing regular in-service education that is based on the outcome of these reviews. The evidence includes: The employee files of six GNAs were reviewed on 11/29/2018 at 10:40 AM. During the review, no performance evaluations could be found that had been performed in the calendar year 2018. The facility Administrator was interviewed concurrently regarding performance evaluations for all of the GNA staff members and confirmed that no reviews had been performed or were planned to be performed in 2018.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to 1) properly date label food that was stored in the main kitchen and 2) store clean dishes in an area that was free from dust and dirt particles landing on top of them and ensure that staff does not place visibly soiled gloves on the same cart with clean dishes. This was found to be evident during an initial tour of the facility during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to 1) ensure the physician re-evaluated the use of an as needed antianxiety medication every 14 days, and 2) & 3) failed to monitor behaviors for residents prescribed antipsychotic medication. This was found to be evident for 3 (Residents #50, #80, and #84) out of 9 residents reviewed for unnecessary medication during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to accurately 1) document the location of a wound, and 2) maintain a medical record in the most accurate form for a resident. This was evident in the review of 2 of 34 residents (Residents #43 and #46) reviewed during the investigation phase of the survey.

Inspectors wroteBased on record review and staff and resident interview it was determined that the facility failed to inform a resident of a change in his/her medication dosage. This was evident for 1 of 9 residents (Resident #84) investigated for unnecessary medications.

Inspectors wroteBased on observation and interview with facility staff and residents' families, it was determined that the facility failed to accommodate the preferences of a nonverbal resident as expressed through his/her family regarding the storage of tube feeding equipment. This was true for 1 of 2 residents (Resident #27) reviewed for tube feeding. The evidence includes: During an observation of Resident #27 that took place on 11/26/2018 at 2:08 PM, Resident #27 was found to be non verbal and not able to respond meaningfully to surveyor questions. The resident's medical record was reviewed concurrently and indicated that the resident was unable to make decisions for him/herself. It was also found that the resident had a feeding tube and received all nutrition and oral medication through the feeding tube. [...]

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to: 1) notify the physician of a resident's ongoing change in condition, and 2) notify the physician when a resident's blood sugar values were above 400. This was evident during the review of 1 of 2 deaths (Resident #93) and 1 out of 9 residents (Resident #35) reviewed for unnecessary medications during the survey.

Inspectors wroteBased on interview and review of pertinent documentation it was determined that the facility failed to follow-up on grievances. This was found to be evident for 2 out of the 4 resident's (Resident #50 and # 94) reviewed for personal property during the survey.

Inspectors wroteBased on review of a facility reported abuse allegation and interview it was determined that the facility failed to ensure accused staff member was removed from patient care immediately following an allegation of abuse. This was found to be evident for 1 out of 5 residents (Resident #4) reviewed for abuse during the survey.

Inspectors wroteBased on record review, resident and staff interview it was determined that the facility failed to accurately report intake information in the Minimum Data Set (MDS) for resident #84. This was evident for 1 of 28 residents (Resident #84) reviewed during the investigation phase of the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a Minimum Data Set (MDS) Assessment inaccurately reflected a residents' status. This was evident for 1 of 9 residents (Resident #46) reviewed for pressure ulcers during the annual survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to follow the interventions identified in a minimally-responsive resident's activity care plan. This was true for 1 of 1 resident (Resident #26) reviewed for activities. The evidence includes: Resident #26 is minimally responsive with an untestable Brief Interview of Mental Status (BIMS). The resident is entirely reliant on staff for quality of life and cannot expressly refuse a provided activity. The Activity Director was interviewed on 11/28/2018 at 10:39 AM. During the interview, the Activity Director stated that Resident #26 is up for activities several days a week and goes to group activities several days per month. [...]

Inspectors wroteBased on record review and staff interviews it was determined that the staff failed to follow the physician treatment order for Resident #13 to keep the patient's right foot elevated to reduce the risk of acquiring a pressure ulcer. This was evident for 1 of 9 residents investigated for skin conditions.

Inspectors wroteBased on observation, record review, and interview with facility staff, it was determined that the facility failed to ensure that a resident only received oxygen with a physician's order. This was true for 1 of 4 residents (Resident #27) reviewed for Respiratory Care.

Inspectors wroteBased on medical record review and interview it was determined that the facility 1) failed to ensure monthly medication regimen reviews were completed by the pharmacist; and 2) failed to ensure the pharmacist identified the continuation an order for the use of an as needed antianxiety medication, in the absence of documentation of its continued need, as an irregularity. This was found to be evident for 2 out of the 9 residents (Resident #35 and #50) reviewed for unnecessary medication during the survey.

Inspectors wroteBased on general observation, wound care observation, and staff interview, it was determined that the facility failed to 1) maintain standard precautions while providing wound care, and 2) & 3) failed to maintain resident care equipment in a manner to prevent the spread of infection and cross contamination. This was evident during the observation of 1 of 2 wound care procedures (Resident #43) and 2 of 2 residents (Residents #79 and #82) reviewed for urinary catheter use.