Oak Crest Village

In the surveyor’s words

From the most serious findings on record at Oak Crest Village, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 6, 2024

  Based on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to ensure that residents remained free of abuse and neglect. This failure led to physical abuse and harm of Resident #135. This finding was evident for 5 of 34 (Resident #135, #130, #117, #122, #125) residents reviewed for abuse during the survey. The findings include: The facility's investigation related to facility-reported incident MD00191125 was reviewed on 8/28/24 at 2:39 PM. In the investigation, the facility substantiated there was an altercation between Resident #132 and Resident #135 which led to Resident #135 sustaining multiple injuries. […]

• Actual harm, isolatedF689Sep 6, 2024

  Based on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to provide adequate supervision to Resident #132 who had a documented history of wandering, agitation, and physically aggressive behaviors as evidenced by the physical abuse and harm of Resident #135. This was evident for 1 (Resident #132) of 4 residents reviewed for accidents and adequate supervision during the survey. The findings include: The facility's investigation related to facility reported incident MD00191125 was reviewed on 8/28/24 at 2:39 PM. In the investigation, the facility substantiated there was an altercation between Resident #132 and Resident #135 which led to Resident #135 sustaining multiple injuries. […]

• Actual harm, isolatedF692Sep 6, 2024

  Based on medical record review, administrative reviews, and staff interview, it was determined that facility staff failed to monitor and implement interventions to address the nutritional needs of residents who had a known significant weight loss. This deficient practice was evident for 5 (#127 and #22, #17, #40, #33) out of 15 residents reviewed for nutrition. The failure resulted in harm to Resident #127. The findings include: 1. On 8/30/24 at 10:47 AM, a review of the facility reported incident MD00201638 dated 01/18/24 alleged Resident #127 was being neglected by staff due to the resident's significant weight loss. […]

• No harm, potential for more than minimal, widespreadF609Sep 6, 2024

  Based on surveyor review of a facility reported incidents, review of medical records, employee records and facility staff interviews, it was determined that the facility failed to report an allegations of abuse, neglect and injuries of unknown origin to the state agency, OHCQ (Office of Health Care Quality) as required. This finding was evident for 16 of 16 residents (Resident #120, #92, #119, #66, #122, #129, #34, #79, #7, #78, #125, #124, #127, #28, #116, #117) selected for abuse investigation. The findings include: The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. […]

• No harm, potential for more than minimal, patternF812Sep 6, 2024

  Based on observations, staff interviews and record review, it was determined that the kitchen failed to store food items so as to maintain the integrity of the specific item and failed to wear gloves while preparing food. This was observed during the initial tour of the kitchen. The findings include: On [DATE] at 7:55 AM an initial tour of the kitchen was done with the Certified Dietary Manager (CDM) Staff # 76. The following concerns were identified: 1. Unlabeled opened cooking oil container on the shelf in the dry kitchen. 2. The cook (staff #77) was observed not wearing gloves while handling and preparing food on food trays. When asked, he placed gloves on without practicing hand hygiene. 3. […]