Oak Crest Village

F 0552 Level of Harm - Minimal harm or potential for actual harm

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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on surveyor observation and interview with staff, it was determined that the facility staff failed to protect the privacy of residents' medical information. This was found to be evident in 1 out of 3 nursing units observed

during a complaint survey.The findings include:On [DATE REDACTED] at 8:10 AM the surveyor observed a cart with a laptop, two pieces of paper, a plastic pitcher of water, 3 small containers (applesauce, vanilla pudding and chocolate pudding), and a pill crusher. The laptop screen was open with patient information visible in the hallway in front of room NG S335. Furthermore, the top paper on the cart had medical information of 11 residents visible that included their MOLST status (Medical Orders for Life-Sustaining Treatment: a medical document that contains a patient's wishes for life-sustaining medical treatments, like CPR and artificial ventilation), their diet, medications, and other important info (as observed on the paper). 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 REDACTED] 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 REDACTED] 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 REDACTED] 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

eating lunch in bed. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of a complaint and of the medical record, interviews with facility staff, and observation, it was determined the facility failed to provide supplements as documented in a resident's care plan and Dining Detail. This was evident for 1 (#312111 regarding Resident #8) of 5 complaints reviewed during the complaint survey. The findings include:A document titled, Dining Details Report- Supporting Nutritional Care provided by the Nursing Home Administrator (NHA) was reviewed on 10/9/25 at 8:10 AM. The review revealed, The Dining Details Report (DDR) is a document that is printed by dining leadership from myUnity (the facility's electronic medical record). Because this report comes directly from the electronic medical record, it contains the most current diet orders, dining preferences, allergies, and all the other details necessary to provide accurate and quality nutritional care for a resident. 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 REDACTED] 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Power Of Attorney. She confirmed that she documented all details in the visit communication notes.During

an interview with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) on 10/08/25, at 11:56 AM, they stated that the facility's nurses should communicate with hospice nurses through care plan meetings and hospice nurses' notes, which facility staff were to review. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Crest Village

8800 Walther Boulevard Parkville, MD 21234

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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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.

Event ID:

Facility ID:

If continuation sheet