Oak Crest Village
OAK CREST VILLAGE in PARKVILLE, MD — inspection on October 10, 2025.
Found 7 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.
Inspection Findings
note.
She verified that there was no documentation to support that facility staff had discussed Resident #16's (or the POA's) wishes regarding the X-ray prior to it being taken.
During an interview with the NHA on 10/10/25 at approximately 12:15 PM, the surveyor shared the above concern, which the NHA validated.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
During the next 7 minutes, the surveyor stood by the cart and heard the nurse speaking to the resident and telling him/her that his/her spouse was going to come and pick up his/her clothes and wash them like s/he always does.
They continued to converse as the surveyor stood outside of the room. On [DATE] at 8:17 AM the surveyor observed the Assistant Director of Nursing (ADON) and asked if she could come down to the cart. In an interview with the ADON, when asked if residents' medical information should be out in and visible for anyone to observe, she stated, No.
The surveyor showed the ADON the open laptop and paper with resident information. On [DATE] at 8:18 AM Licensed Practical Nurse (LPN #8) exited the resident's room and walked upon the surveyor and ADON who were standing at her cart. In an interview with LPN #8 when asked if resident information should be out and visible she stated, No, it should always be covered up, but I went in the room because I did not like the way the resident was sitting. S/he was leaning.
During the interview, the surveyor shared that they were standing out front of the room for 7 minutes and that someone walked by while the information was out.
The surveyor shared this was a concern and the ADON and LPN #8 acknowledged understanding. On [DATE] at 9:12 AM the surveyor shared the above concern with the Nursing Home Administrator (NHA).
The NHA stated the resident was about to fall and that is why the nurse went in there.
The surveyor stated that they heard the nurse and resident calmly conversing about day to day tasks.
Additionally, the surveyor stood outside the room near the cart for 7-8 minutes and observed someone walking by with the information out.
The NHA stated he understood the concern.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
Based on medical records review and staff interview, it was determined the facility staff failed to revise interdisciplinary care plans to reflect accurate interventions for residents.
This was evident for one (Resident #21) of the six residents reviewed for injuries of unknown origin during this complaint survey.The findings included:On 10/06/25, at 2:07 PM, the surveyor reviewed facility's self-reported incident (312135) concerning Resident #21, who reported bruises on both arms on 11/04/24.
The facility staff investigated this as an unknown origin of injury and concluded that the bruises resulted from Resident #21 propelling their wheelchair, during which their arms hit and rubbed against the wheelchair and the wheelchair brake extenders. In an interview with the Rehab Director (Staff #4) on 10/07/25, at 11:13 AM, he verified that Resident #21's initial evaluation, dated 5/22/24, stated that the resident required assist but was able to self-propel wheelchair.
Furthermore, after the incident reported on 11/04/24, a therapist assessed Resident #21 and verified that self-propelling a wheelchair with an extended brake would be beneficial for the resident.
During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/07/25 at 11:37 AM, the NHA confirmed that the facility's investigation concluded that Resident #21's bruises resulted from the extensions of the wheelchair brake.
Additionally, the surveyor asked about interventions provided to prevent similar incidents.
The NHA said that the rehab team evaluated the resident and documented their findings.
The surveyor requested any documentation to support how the facility staff revised the plan of care for this resident. On 10/07/25, at 1:03 PM, the DON and NHA stated that the interventions for Resident #21 were documented in the progress notes; however, they were not updated on the care plan.
The surveyor shared a concern that Resident #21's risk of bruises due to extended wheelchair brakes was not updated in the resident care plan.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
The surveyor observed a sandwich, a drink, and sliced peaches in a white bowl with a fork; however, it was not a built up fork. On 10/8/25 at 12:40 PM the surveyor requested a dual observation of the concerns and interview with the ADON.
The surveyor stood outside the room as the ADON entered the resident's room and greeted Resident #8.
Upon exiting the room and when asked if the ADON observed a plate guard, she stated no.
When asked if she observed built up utensils, she stated no.
When asked why the resident did not have the built up utensils, she proceeded to reenter the resident's room and open the top drawer of his dresser.
Then, she pulled out the plate guard and built up utensils wrapped in a napkin.
Upon exiting the room and when asked why they were not being used, she stated s/he did not need utensils for a sandwich.
The surveyor stated that s/he had a fork with his/her peaches; however, it was not a built up fork.
The surveyor shared this along with not having the plate guard applied was a concern and she stated, I agree.On 10/8/25 at 1:50 PM the surveyor shared the concerns with the NHA who stated that he understood that Resident #8 was provided with the plate guard and built up utensils.
The surveyor shared it was after surveyor intervention and that GNA #10 had stated that there were some room changes recently including Resident #8 and s/he was a newer resident on her assignment.
The NHA stated, I am glad it was caught, and we will reeducate as well.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
Review of complaint 312111 on 10/7/25 at 10:01 AM revealed the complainant noted that Resident #8 did not receive ice cream with lunch, did not receive milkshake at 2 p.m., did not receive super spuds with lunch, did not receive a drink with lunch.
Furthermore, the complaint noted that medical and nursing staff recommended hospice because s/he was losing weight; however, the ice cream, shakes and super spuds were interventions that the facility put in place but as noted above, did not hold to.
Review of the medical record on 10/7/25 at 8:17 AM revealed Resident #8 was originally admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's with dyskinesia, dementia, dysphagia, and other chronic pain.On 10/8/25 at 8:29 AM in an interview with Geriatric Nursing Assistant (GNA #10) when asked where do you look to determine if a resident needs feeding assistance or has any other feeding needs, she stated on the long sheet in the nurse's station, in their chart, or on the Dining Detail. On 10/8/25 at 9:00 AM a copy of the Dining Details that hangs on the wall between the kitchen and dining room was provided by the ADON.
Review of the Dining Details revealed that Resident #8's Supplements should include L/D (lunch and dinner): vanilla ice cream and mashed potatoes with gravy. On 10/8/25 at 9:32 AM review of Resident #8's care plan revealed, Care Plan Approaches: Super spuds with lunch and dinner and ice cream with lunch and dinner.
Further review revealed, a care plan update on 9/9/24 that the resident is offered in house shake at 2pm and super spuds with lunch and dinner.
Additionally, on 9/13/24 the care plan was updated to ice cream with all meals and 2 in house shakes.
Also, on 11/8/24 the care plan was updated, Resident did not want ice cream with breakfast just with lunch and dinner. In addition, on 12/4/24 it was noted Continue to offer in house shake at 2pm, ice cream and super spuds with lunch and dinner.
Finally, on 3/12/25 it was noted, no changes to the nutrition plan of care and to continue the plan of care.On 10/8/25 at 12:34 PM Resident #8 was observed eating lunch in bed.
The surveyor observed a sandwich, a drink, and sliced peaches in a white bowl; however, the observation did not include visualization of super spuds with gravy or vanilla ice cream. On 10/8/25 at 12:40 PM the surveyor requested a dual observation of the concerns and interview with the Assistant Director of Nursing (ADON).
The surveyor stood outside the room as the ADON entered the resident's room and greeted Resident #8.
Upon exiting the room and when asked if the ADON observed mashed potatoes (super spuds) with gravy, she stated no.
When asked if she observed vanilla ice cream, she stated no.
The surveyor shared this was a concern and she stated, I agree.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
The surveyor reviewed Resident #16's medical records including hospice visit communication notes and progress notes with the ADON and NHA.
They confirmed that there was no documentation to support the facility's nursing staff acknowledged discussion between hospice nurses and Resident #16's POA.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/10/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest Village
8800 Walther Boulevard Parkville, MD 21234
SUMMARY STATEMENT OF DEFICIENCIES
Based on review of facility reported incidents, review of employee records, and interview with facility staff, it was determined that the facility failed to have documentation that a Care Associate (CA) was given abuse training after returning from suspension related to an allegation of abuse.
This was evident for 1 (CA #18) of 2 Care Associates records reviewed during this complaint survey.The findings include:On 10/9/25 at 10:05 AM a review of a Facility Reported Investigation (FRI) noted that Resident # 2 complained that on 6/11/25 evening shift, a Care Associate (CA) pushed and pulled him around and unplugged his television.
The resident denied pain at time of assessment and the resident's wife stated that resident appeared more confused, however the resident was able to provide a description of the CA #18.An interview was conducted with CA #18 on 6/12/2025 who stated that he/she had received report from the nurse to be very careful with the resident's Left arm.
Resident was sitting in a chair and was assisted with changing his/her clothes and transferred to bed. CA #18 further stated that the television was on, and the resident was talking about the weather on the television. CA#18 denied turning off the television or unplugging the television and resident did not have any complaints about his/her care.As part of the investigation, the facility interviewed the staff that worked with Resident #2 on the evening and night shifts of 6/11/25 and day shift of 6/12/25.
All staff denied that the television was unplugged and that the resident had been having bouts of confusion.
Five residents on the same assignment as Resident #2 denied feeling mistreated and stated that they feel safe in the facility.A review of the actions taken by the facility on 10/09/2025 at 12:34 PM revealed that the facility notified the resident's wife, Baltimore County Police Department (BCPD), the Ombudsman, and Adult protective Services. An Xray was ordered on 6/12/25 of resident's left shoulder and arm, which was negative for a fracture or dislocation and showed moderate degenerative joint disease. CA #18 was suspended during the investigation.
The conclusion of the investigation was that the allegation of abuse was not verified based on resident's interview, staff interviews, and the resident's history of dementia, confusion, and memory impairment.
Review of the CA#18 personnel record on 10/9/2025 at 12:42 PM revealed that no training of abuse was conducted following the suspension date of 6/12/2025 and upon returning to work.On 10/9/25 at 12:50 PM in an interview with the Nursing Home Administrator (NHA), he stated that abuse training is done at least annually and in the case of an allegation of abuse, training is done before returning to work through a system called Workday.
This is Human Resources (HR) system where there is a learning portion on abuse.
When surveyor asked how do you know when training is completed, the NHA stated that he would communicate with HR to verify who had completed the training.On 10/09/2025 at 1:10 PM, the NHA was made aware that it was a concern that CA#18 had not completed abuse training after returning to work from suspension.
The NHA verified and agreed that abuse training should have been done.
Facility ID: