Inspection Reports for
Oak Crest Village
8830 Walther Boulevard, Parkville, MD, 21234
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaints regarding resident care, privacy breaches, care plan accuracy, provision of assistive devices, hospice coordination, and staff training.
Complaint Details
The complaint investigation included review of incidents involving failure to inform POA before diagnostic procedures, privacy breaches, inaccurate care plans, lack of assistive devices and nutritional supplements, poor hospice coordination, and missing abuse training documentation for staff. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to fully inform a resident's Power of Attorney before diagnostic procedures, failure to protect residents' medical information privacy, failure to update care plans to reflect accurate interventions, failure to provide assistive devices and nutritional supplements as documented, failure to coordinate hospice care effectively, and failure to provide abuse training to a Care Associate after suspension.
Deficiencies (7)
F 0552: Facility staff failed to fully inform the Power of Attorney of a resident before conducting a diagnostic X-ray, despite prior refusal by the POA and hospice nurse.
F 0583: Facility staff failed to protect the privacy of residents' medical information by leaving patient data visible on a laptop and papers in a hallway.
F 0657: Facility staff failed to revise interdisciplinary care plans to reflect accurate interventions for a resident's risk of bruising due to wheelchair brake extensions.
F 0676: Facility failed to provide assistive devices such as built-up utensils and plate guards to a resident, limiting their ability to perform activities of daily living independently.
F 0684: Facility failed to provide nutritional supplements including ice cream and mashed potatoes as documented in a resident's care plan and Dining Details.
F 0849: Facility failed to coordinate care for a resident receiving hospice services, lacking documentation of communication between facility nursing staff and hospice nurses or the resident's POA.
F 0943: Facility failed to provide abuse training documentation for a Care Associate after returning from suspension related to an abuse allegation.
Report Facts
Residents reviewed for injury of unknown origin: 6
Residents reviewed for care during complaint survey: 22
Complaints reviewed: 5
Date of survey completion: Oct 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #16 | Attending Nurse Practitioner | Named in medication and diagnostic procedure findings related to Resident #16. |
| Staff #17 | Hospice Nurse | Interviewed regarding hospice care coordination for Resident #16. |
| Staff #19 | Licensed Practical Nurse | Wrote clinical notes related to Resident #16's diagnostic procedure. |
| CA #18 | Care Associate | Involved in abuse allegation and training deficiency. |
| Staff #4 | Rehab Director | Interviewed regarding care plan revisions for Resident #21. |
| GNA #10 | Geriatric Nursing Assistant | Interviewed regarding feeding assistance and nutritional care for Resident #8. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed multiple times regarding various deficiencies. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed multiple times regarding facility deficiencies and investigations. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 6, 2024
Visit Reason
The survey was conducted as part of the annual inspection to assess compliance with regulatory requirements including resident care, abuse prevention, nutrition, medication administration, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to prevent abuse and neglect, inadequate supervision of residents with behavioral issues, failure to timely report abuse allegations, failure to monitor and intervene for significant weight loss, medication administration errors, food safety violations in the kitchen, and lack of documentation verifying resident showers.
Deficiencies (11)
F 0550: The facility failed to treat a resident with dignity by improperly turning the resident using arms instead of a draw sheet, resulting in bruises.
F 0558: The facility failed to accommodate a resident's dietary needs by not assisting with opening containers and cutting food as required.
F 0600: The facility failed to protect residents from abuse and neglect, substantiating multiple abuse incidents including physical abuse and neglect, and failed to provide adequate supervision for a resident with behavioral disturbances.
F 0609: The facility failed to timely report allegations of abuse, neglect, and injuries of unknown origin to the state agency within required timeframes.
F 0610: The facility failed to ensure staff reported suspected abuse timely, allowing an alleged perpetrator to continue providing care to the victim prior to investigation.
F 0658: The facility failed to follow professional nursing standards by not signing medication records after administering antibiotics.
F 0684: The facility failed to administer antibiotic therapy as ordered, resulting in missed doses and delayed treatment.
F 0689: The facility failed to provide adequate supervision to a resident with documented agitation and aggression, resulting in physical harm to another resident.
F 0692: The facility failed to monitor and intervene for significant weight loss in multiple residents, resulting in harm due to ongoing weight loss and delayed interventions.
F 0812: The kitchen failed to store food properly, maintain food safety standards, and staff failed to wear gloves while preparing food.
F 0842: The facility failed to provide documentation verifying that a resident received a shower during their admission.
Report Facts
Weight loss: 16
Weight loss percentage: 8.17
Weight loss percentage: 15
Weight loss percentage: 33.2
Weight loss percentage: 50
Weight loss percentage: 8.77
Weight loss percentage: 9.09
Weight loss percentage: 10.31
Weight loss percentage: 12.92
Weight loss percentage: 15.23
Weight loss percentage: 28.49
Weight loss percentage: 26.01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #66 | Geriatric Nursing Assistant | Admitted to improper turning of Resident #5 causing bruises. |
| Staff #38 | Refused to provide care to a COVID resident and was terminated for neglect. | |
| GNA #68 | Geriatric Nursing Assistant | Substantiated abuse allegations for rough handling of Resident #125. |
| CA #42 | Care Associate | Alleged mishandling of Resident #28 and continued working with resident after report. |
| Nurse #70 | Administered antibiotic to Resident #123 but failed to sign medication record. | |
| RN #5 | Registered Nurse | Nurse for Resident #135 during altercation with Resident #132. |
| LPN #27 | Licensed Practical Nurse | Nurse for Resident #132 on day of incident; reported inconsistent PDA presence. |
| CA #47 | Care Associate | Witnessed altercation between Resident #132 and Resident #135. |
| RD #36 | Registered Dietician | Reported significant weight loss for multiple residents and delayed interventions. |
| NP #51 | Nurse Practitioner | Provided follow-up care for Resident #22 and Resident #127 weight loss. |
| ADON #13 | Assistant Director of Nursing | Acknowledged lack of documentation and interventions for Resident #132 and others. |
| Administrator #1 | Administrator | Acknowledged late reporting of abuse and other deficiencies. |
| Medical Director #25 | Medical Director | Acknowledged delays in addressing weight loss and lack of documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 6, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication administration, treatment adherence, and documentation practices at the nursing facility.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors, missed antibiotic doses, and inadequate documentation of resident care. The deficiencies were substantiated based on medical record reviews and staff interviews.
Findings
The facility failed to follow professional nursing standards by not signing medication records after administration, missed doses of antibiotic therapy, and lack of documentation verifying resident showers. These deficiencies affected Resident #123 and were confirmed through medical record reviews and staff interviews.
Deficiencies (3)
F 0658: Facility staff failed to sign the medication record after administering an antibiotic to Resident #123, violating professional nursing standards.
F 0684: Facility staff failed to administer antibiotic therapy as ordered, resulting in missed doses for Resident #123.
F 0842: Facility staff failed to provide documentation verifying Resident #123 received a shower during admission, contrary to professional standards.
Report Facts
Residents affected: 1
Medical records reviewed: 2
Missed antibiotic doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing RN #9 | Assistant Director of Nursing | Interviewed regarding medication administration and monitoring |
| Nurse #70 | Nurse | Administered antibiotic but failed to sign medication record |
| Nurse #78 | Nurse | Noted unavailability of prescribed IV antibiotic |
| RN #5 | Registered Nurse | Interviewed about medication administration expectations |
| Director of Nursing #8 | Director of Nursing | Interviewed about shower/skin sheet documentation |
| Administrator #1 | Administrator | Interviewed about documentation practices for resident showers |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 11, 2019
Visit Reason
The annual recertification survey was conducted to assess compliance with federal nursing home regulations and ensure quality of care and safety for residents.
Findings
The facility was found deficient in multiple areas including failure to feed residents simultaneously, unsafe and unclean environment, failure to notify residents or representatives of hospital transfers, inaccurate resident assessments, delayed oxygen treatment, failure to obtain ordered weights, failure to post nurse staffing information accessibly, and ineffective pest control evidenced by mouse sightings.
Deficiencies (8)
F 0550: Facility staff failed to ensure residents were fed at the same time during dining observations on 10/3/19 and 10/4/19.
F 0584: Facility failed to provide a safe, clean, comfortable, and homelike environment; torn screen window and missing cove molding were observed.
F 0623: Facility staff failed to notify Resident #152 or responsible party in writing of the reason for hospital transfer on 7/15/19.
F 0641: Facility staff failed to accurately document assessment of restraints for Resident #20 on the MDS; resident was restraint free but coded otherwise.
F 0658: Facility staff failed to immediately place oxygen on Resident #453 when oxygen saturation dropped to 91%, delaying treatment.
F 0684: Facility staff failed to obtain weights as ordered for Resident #152 on 7/3/19 and 7/5/19 for acute CHF diagnosis.
F 0732: Facility failed to post nursing staffing data in a readily accessible area for residents and visitors; staffing board was behind reception desk.
F 0925: Facility failed to maintain an effective pest control program as evidenced by presence of a mouse in the Cardinal Cove Activities Room.
Report Facts
Residents reviewed: 71
Residents affected: 1
Residents affected: 1
Residents affected: 1
Nursing assignment boards observed: 4
Nursing assignment boards deficient: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding feeding times, restraint assessment, hospital transfer notification, oxygen treatment, and weight measurements | |
| Administrator | Interviewed regarding feeding times, environment deficiencies, hospital transfer notification, oxygen treatment, and staffing board posting |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 13, 2018
Visit Reason
The inspection was conducted as part of the annual survey process to assess compliance with healthcare regulations and standards at Oak Crest Village nursing home.
Findings
The facility failed to meet several regulatory requirements including honoring residents' advance directives and end-of-life wishes, providing timely notification for emergency transfers, documenting accurate MDS assessments, addressing physician orders and lab results timely, following physician orders for resident care, maintaining complete medical records, and having policies for medication regimen review.
Deficiencies (7)
F578: Facility staff failed to ensure criteria were met for residents' Advance Directives to become effective and failed to honor end-of-life wishes for multiple residents by performing unauthorized vital signs and lab tests.
F623: Facility staff failed to provide written notice to residents, representatives, and ombudsman for emergency transfers for 3 residents.
F641: Facility staff failed to document accurate MDS assessments by omitting oxygen therapy for a resident with COPD.
F684: Facility staff failed to notify physician timely of urinalysis results and failed to follow physician's order for no right arm procedures for a resident with a right mastectomy.
F695: Facility staff failed to follow physician's order to document oxygen saturations for a resident on oxygen therapy.
F756: Facility failed to have policies and procedures in place for medication regimen review to address irregularities and protect residents.
F842: Facility staff failed to maintain complete and accurate medical records by omitting allergy information for a resident.
Report Facts
Residents reviewed: 64
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
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