Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations regarding improper use of physical restraints and deficiencies in care planning and medical record documentation at Mallard Bay Nursing and Rehab.
Complaint Details
The complaint involved Resident #2 being physically restrained with a gait belt in a wheelchair without an order, which was confirmed by multiple witness statements and photographic evidence. The investigation revealed staff awareness but failure to act promptly. Additional complaints included failure to update care plans for Resident #1 and incomplete medication documentation for Residents #1 and #3.
Findings
The facility was found to have failed to maintain an environment free from physical restraints for one resident, failed to update care plans to reflect current treatments for one resident, and failed to ensure complete and accurate medical record documentation for two residents. Several staff members were implicated in the restraint incident, and disciplinary actions were taken.
Deficiencies (3)
Failure to ensure each resident is free from the use of physical restraints unless medically necessary.
Failure to develop and revise the complete care plan within 7 days of the comprehensive assessment to reflect accurate interventions.
Failure to safeguard resident-identifiable information and maintain complete and accurate medical records, including documentation for medication administration and PICC line site location.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Dates of medication non-administration: 15
PICC line in place duration (days): 138
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geriatric Nursing Assistant #5 | GNA | Reported and documented the restraint incident involving Resident #2 |
| Licensed Practical Nurse #6 | LPN | Informed about restraint incident and involved in follow-up |
| Occupational Therapist #7 | OT | Notified staff about restraint incident and provided photographic evidence |
| Licensed Practical Nurse #10 | LPN | Received reports and photos regarding restraint incident |
| Director of Nursing | DON | Interviewed regarding restraint incident and care plan deficiencies |
| Unit Manager LPN #3 | Unit Manager LPN | Confirmed care plan deficiencies for Resident #1 |
| Registered Nurse #1 | RN | Interviewed about medication documentation deficiencies |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Sep 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (Resident #59) who reportedly had maggots in their wound on two occasions.
Complaint Details
The complaint investigation found substantiated evidence that Resident #59 had maggots in their wound on two occasions, but the facility failed to document these incidents or provide timely wound care documentation. Staff including the Unit Manager, DON, and ADON acknowledged awareness but could not provide documentation or explanation.
Findings
The facility failed to ensure residents received treatment and care according to professional standards. Resident #59 had maggots in their wound twice, but there was no documentation of these incidents in the medical records. Dressing changes were not properly documented, with the last documented dressing change occurring several days before the actual change.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders and resident preferences, specifically related to wound care and documentation of maggot infestation.
Report Facts
Residents reviewed: 40
Resident affected: 1
Date of survey completion: Sep 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #3 | Unit Manager and Assistant Director of Nursing (ADON) | Aware of maggot incidents but unable to provide documentation |
| DON #2 | Director of Nursing | Aware of maggot incidents but unable to provide documentation or explanation |
| RN #21 | Registered Nurse | Performed dressing change on 9/4/25 and was informed about previous undocumented dressing change |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 5, 2025
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements and ensure resident safety, dignity, and quality of care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, improper handling and misappropriation of controlled medications, inadequate communication with dialysis centers, incomplete care plans, failure to provide appropriate wound care documentation, failure to provide assistive vision devices, unsafe wheelchair use, falsification of resident weights, incomplete medical records, and lapses in infection control practices during medication administration.
Deficiencies (11)
Failure to maintain resident dignity and privacy, including exposed Foley catheter bag and staff not wearing identification badges.
Failure to maintain a safe, clean, comfortable, and homelike environment due to room maintenance issues.
Misappropriation of Resident #76's prescribed oxycodone by RN #25 following discharge.
Failure to timely report suspected abuse, neglect, or theft to proper authorities (OHCQ) regarding misappropriation of medication.
Failure to develop and implement a complete care plan ensuring communication between dialysis center and facility for Resident #93.
Failure to maintain accountability and proper destruction of controlled substances resulting in medication diversion.
Failure to provide appropriate wound care documentation and treatment for Resident #59 who had maggots in wound on two occasions.
Failure to ensure Resident #7 received prescribed glasses and proper vision services.
Failure to ensure wheelchair used for transporting Resident #19 had leg lifts in place, resulting in unsafe transport.
Falsification of resident weights by Assistant Director of Nursing and incomplete medical records including missing medication indications and wound care documentation.
Failure to follow infection prevention and control guidelines during medication administration, including improper handling of medications and empty hand sanitizer dispensers.
Report Facts
Residents reviewed: 40
Medication diversion incident date: 202408
Dates with missing dialysis communication: 12
Weight entries: 10
Medication count in pill cup: 8
Empty hand sanitizer dispensers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #25 | Registered Nurse | Named in medication diversion and misappropriation of Resident #76's oxycodone |
| LPN #24 | Licensed Practical Nurse | Cosigned narcotic destruction record without witnessing destruction |
| Director of Nursing | Director of Nursing | Interviewed regarding staff not wearing ID badges, medication diversion, and documentation issues |
| Human Resources Assistant (Staff #6) | Human Resources Assistant | Confirmed ID badge machine was not working |
| DON #2 | Director of Nursing | Interviewed about wound care, medication indication documentation, and vision services |
| Unit Manager #3 | Assistant Director of Nursing / Unit Manager | Aware of maggot wound incidents but unable to provide documentation |
| LPN #20 | Licensed Practical Nurse | Observed improperly handling medications during administration |
| RN #21 | Registered Nurse | Performed wound dressing change for Resident #59 |
| GNA #33 | Geriatric Nursing Assistant | Witnessed wound dressing change for Resident #59 |
| Staff #11 | Nurse | Not wearing ID badge during care |
| Staff #22 | Registered Nurse | Observed plucking medications directly from blister packs into bare hands |
| Staff #35 | Business Manager | Interviewed about Resident #7's insurance and vision services |
| Director of Rehabilitation (DOR) Staff #17 | Director of Rehabilitation | Interviewed about wheelchair transport incident involving Resident #19 |
| Physical Therapy Assistant Staff #18 | Physical Therapy Assistant | Involved in incident where Resident #19's leg bent backwards during therapy and transport |
Inspection Report
Complaint Investigation
Capacity: 160
Deficiencies: 17
Date: Apr 29, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging deficiencies in care, including failure to provide adequate assistance, medication errors, neglect, abuse reporting failures, and insufficient staffing.
Complaint Details
The complaint investigation was triggered by multiple complaints alleging neglect, abuse, inadequate staffing, medication errors, failure to provide care such as showers, failure to notify families and physicians, and failure to maintain accurate records.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, failure to notify physicians and responsible parties of changes in condition, failure to provide adequate care such as showers and wound care, failure to maintain accurate and complete medical records, failure to provide timely medication administration, failure to conduct thorough investigations of abuse allegations, failure to maintain adequate staffing levels, failure to provide dental care, and failure to employ a full-time licensed Nursing Home Administrator and social worker.
Deficiencies (17)
Failure to ensure residents' call lights were within reach and residents were positioned comfortably.
Failure to notify physician and responsible party of changes in condition including low blood sugar and weight loss.
Failure to respect resident privacy during visitor interactions.
Failure to provide required services leading to neglect, including leaving a resident in soiled brief for hours.
Failure to timely report suspected abuse and neglect to regulatory authorities.
Failure to thoroughly investigate allegations of abuse.
Failure to complete timely and comprehensive Minimum Data Set (MDS) assessments including resident interviews.
Failure to ensure accurate MDS assessments and coding, including failure to capture falls, medications, and hospice status.
Failure to develop and implement a comprehensive nutritional care plan for a resident with significant weight loss.
Failure to update care plans after changes in condition such as falls and weight loss.
Failure to provide documentation that residents were offered or received showers as scheduled.
Failure to keep a resident with decreased cognition from exiting the building unsupervised.
Failure to maintain complete and accurate medical records including documentation of neuro checks and assessments after falls.
Failure to provide timely medication administration and to monitor blood pressure prior to administering blood pressure medications.
Failure to provide dental care for a resident with a missing tooth and failure to notify family.
Failure to employ a full-time licensed Nursing Home Administrator authorized by the State of Maryland for specified periods.
Failure to employ a full-time qualified social worker in a facility with more than 120 beds.
Report Facts
Residents reviewed: 52
Licensed capacity: 160
Weight loss: 9.4
Staffing hours per resident per day: 3
Staffing hours per resident per day: 2.31
Staffing hours per resident per day: 2.32
Staffing hours per resident per day: 2.64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed and involved in multiple findings including call light issues, medication errors, and investigations |
| Staff #12 | Housekeeper | Involved in privacy violation incident with Resident #8 |
| Staff #55 | Geriatric Nursing Assistant (GNA) | Failed to provide care to Resident #46, written up for unsatisfactory work |
| Staff #30 | Geriatric Nursing Assistant (GNA) | Failed to answer call bells for Resident #46 |
| Medical Director | Medical Director | Interviewed regarding multiple findings including weight loss and medication errors |
| LPN #22 | Licensed Practical Nurse | Interviewed about weight process and dietician notification |
| MDS Coordinator #17 | MDS Coordinator | Interviewed regarding MDS assessment errors |
| Staff #4 | Social Work Assistant | Interviewed regarding lack of full-time social worker |
| Staff #39 | Nurse | Failed to change wound dressing for Resident #31 |
| Staff #31 | Nurse | Interviewed regarding neglect of Resident #46 |
| Staff #58 | Staff | Interviewed regarding staffing control by corporate |
| Certified Medicine Aide #57 | Certified Medicine Aide | Interviewed regarding blood pressure monitoring and medication administration |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 26, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in several areas including failure to timely notify a resident's physician of treatment changes, failure to provide timely notification of emergency transfers to the Ombudsman, inadequate pressure ulcer care, failure to address significant resident weight gain, failure to serve meals according to resident preferences, and failure to maintain complete and accurate medical records for immunizations.
Deficiencies (6)
Facility staff failed to notify a resident's physician when a treatment plan had changed (Resident #187).
Facility staff failed to provide written notice for emergency transfers to the Ombudsman (Resident #71).
Facility staff failed to provide treatment/services to prevent/heal pressure ulcers (Residents #14 and #70).
Facility failed to ensure the physician addressed a resident's significant weight gain (Resident #51).
Facility staff failed to serve meals as requested by residents (Residents #33 and #62).
Facility staff failed to maintain the medical record in the most complete and accurate form for preventive health care immunization (Residents #25, #51, and #73).
Report Facts
Residents reviewed for notification deficiency: 59
Residents reviewed for emergency transfer notification: 1
Residents reviewed for pressure ulcers: 6
Residents reviewed for weight gain/loss: 7
Residents reviewed for dining: 24
Residents reviewed for immunization records: 5
Weight gain percentage: 11.57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed failure to notify physician timely and failure to follow wound NP treatments | |
| Administrator | Unaware of regulation regarding emergency transfer notification |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Dec 4, 2018
Visit Reason
The survey was conducted as part of the facility's annual Medicare/Medicaid inspection to assess compliance with regulatory requirements and investigate specific concerns including medication management, resident care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to inform residents of medication changes, failure to accommodate resident preferences, failure to notify physicians of significant clinical changes, inadequate grievance follow-up, failure to remove accused staff after abuse allegations, inaccurate resident assessments, failure to follow care plans, improper respiratory care, lack of staff performance reviews, incomplete pharmacist medication reviews, failure to monitor psychotropic medication use, improper food storage and labeling, inaccurate medical record documentation, and infection control lapses.
Deficiencies (15)
Failed to inform a resident of a change in medication dosage.
Failed to accommodate the preferences of a nonverbal resident regarding storage of feeding tube equipment.
Failed to notify physician of resident's ongoing change in condition and elevated blood sugar levels.
Failed to follow-up on resident grievances regarding missing personal property.
Failed to remove accused staff member from resident care immediately following abuse allegation.
Failed to accurately report resident admission source in Minimum Data Set (MDS).
Failed to ensure accurate MDS assessment regarding pressure ulcers.
Failed to follow physician order to keep resident's right foot elevated to reduce pressure ulcer risk.
Failed to ensure resident only received oxygen with a physician's order.
Failed to provide performance reviews for Geriatric Nursing Assistants in 2018.
Failed to ensure monthly pharmacist medication regimen reviews and identify irregularities related to antianxiety medication use.
Failed to implement gradual dose reductions and monitor behaviors for residents on psychotropic medications.
Failed to properly date label food and store clean dishes free from contamination.
Failed to accurately document wound location and maintain accurate medical records.
Failed to maintain standard precautions during wound care and prevent cross contamination with urinary catheter equipment.
Report Facts
Medication administration: 7
Blood sugar readings above 400: 25
Blood sugar readings above 550: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #16 | Physician | Interviewed regarding medication changes and resident condition |
| GNA #19 | Geriatric Nursing Assistant | Accused of abuse and not removed from resident care immediately |
| Staff #13 | Provided clarification on pressure ulcer documentation | |
| Staff #8 | Performed wound care observed during survey | |
| Staff #14 | Confirmed lack of behavior monitoring for antipsychotic medication | |
| Staff #32 | Nurse | Interviewed regarding oxygen order and palliative care documentation |
| Staff #33 | Corporate Registered Nurse | Interviewed regarding oxygen order documentation |
| Staff #34 | Registered Nurse | Observed resident's foot elevation status |
| Staff #25 | Geriatric Nursing Assistant | Interviewed regarding resident foot elevation and laundry concerns |
| Staff #21 | Confirmed unsanitary storage of urinary catheter drainage bag | |
| Staff #12 | MDS Coordinator | Interviewed regarding resident admission source |
| Staff #11 | Interviewed regarding wound documentation errors | |
| Administrator | Administrator | Interviewed and made aware of multiple concerns |
| Director of Nursing | Director of Nursing | Interviewed and made aware of multiple concerns |
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