Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Crest Village during CMS and state inspections, most recent first.
Facility staff did not fully inform the POA of a resident receiving hospice care before performing an X-ray, despite a prior refusal of the procedure. Documentation was inconsistent regarding the POA's wishes, and staff confirmed there was no evidence of consultation with the POA before the X-ray was conducted.
Staff failed to maintain the confidentiality of resident medical records when a cart with an open laptop displaying patient information and a paper listing details for 11 residents, including MOLST status and medications, was left unattended and visible in a hallway. An LPN left the cart to attend to a resident, and both the ADON and LPN later acknowledged that the information should have been covered.
Facility staff did not update the care plan for a resident who developed arm bruises from contact with wheelchair brake extenders while self-propelling. Although the incident and related interventions were documented in progress notes, the care plan was not revised to reflect the resident's risk and necessary interventions.
A resident with Parkinson's disease and other conditions requiring adaptive eating equipment was not provided with built-up utensils or a plate guard during a meal, despite these being specified in the care plan and facility documentation. The necessary devices were found stored in the resident's room and not in use, and staff were unaware of the oversight until it was pointed out by a surveyor.
A resident with complex medical needs did not receive prescribed nutritional supplements, including ice cream and mashed potatoes with gravy, as outlined in their care plan and Dining Detail. Direct observation and staff interviews confirmed these items were missing from the resident's meal, despite clear documentation of the requirement.
A resident receiving hospice care experienced worsening symptoms of a swollen and painful knee. While a hospice nurse suspected a possible disarticulation and discussed care decisions with the resident's power of attorney, this information was not communicated to facility nursing staff. Facility staff primarily relied on verbal updates and did not formally document or review hospice notes, resulting in a lack of coordinated care and documentation.
A Care Associate returned to work after suspension for an abuse allegation involving a resident with dementia, but there was no documentation that required abuse training was completed prior to their return. The Nursing Home Administrator confirmed that such training is required but was not done in this case.
The facility failed to protect residents from abuse and neglect, resulting in multiple incidents. One resident with severe dementia and aggressive behavior was not consistently supervised, leading to a physical altercation with another resident. Another incident involved a resident being left on a bedpan for an extended period, resulting in discomfort. Additional incidents included a staff member refusing to care for a COVID-positive resident and another providing rough incontinence care. These incidents highlight inadequate care and supervision.
A resident with severe cognitive impairment and a history of aggression was inadequately supervised, leading to an altercation with another resident. Despite a care plan requiring supervision, the facility failed to ensure the consistent presence of a Private Duty Aide, contributing to the incident. The lack of documentation and communication regarding the resident's care and supervision further exacerbated the deficiency.
The facility failed to monitor and address significant weight loss in multiple residents, including one who lost over 50 pounds. Despite being aware of the weight loss, staff did not implement timely dietary interventions or conduct consistent weight checks. Observations showed residents not consuming meals, and there were delays in updating care plans and notifying medical staff.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the state agency within the required timeframes for 16 residents. Incidents were reported late, with initial reports submitted hours after the required timeframe and final reports delayed beyond the five-day limit. Interviews with staff confirmed lapses in timely reporting, despite the facility's policy mandating immediate reporting.
During a kitchen tour, several deficiencies were noted, including unlabeled cooking oil, a cook not wearing gloves or practicing hand hygiene, and expired food items in the freezer. Additionally, sanitizer test strips were improperly stored, and logs for the sanitizer and dish machine temperatures were incomplete. Ice buildup was also observed in a walk-in freezer. These issues were communicated to the Certified Dietary Manager.
A resident experienced a lack of dignity when a GNA improperly turned them using their arms instead of a draw sheet, resulting in bruising. The resident was on Aspirin as a blood thinner at the time.
A resident's dietary needs were not accommodated as required. The resident needed assistance with opening containers and cutting food, as well as specific dietary supplements. Observations showed the resident's meal tray had an uncut sandwich, unopened ice cream, and untouched fruit cup, indicating a lack of provided assistance.
A facility failed to report suspected abuse in a timely manner, allowing the alleged perpetrator, a CA, to continue working with the resident before the investigation began. The incident was reported by an LPN to an RN, but the state agency was not notified until the next day. Despite facility policy, the CA was not immediately suspended and continued to work a double shift with the resident.
Facility staff did not follow professional nursing standards by failing to sign the medication record after administering an antibiotic to a resident. An alternative antibiotic was ordered and given by a nurse, but the administration was not documented in the medication record. Interviews with the Assistant Director of Nursing and a registered nurse confirmed that nurses are expected to sign the medication record after administering medications.
A resident with a prosthetic hip infection was prescribed Cefazolin IV every 8 hours, but the facility failed to administer the first dose and another subsequent dose. An alternative antibiotic was given without proper documentation. The ADON stated that medication administration is monitored weekly through exception reports.
Facility staff failed to document a resident's shower during admission. The DON explained that a shower/skin sheet is usually completed by GNAs and the assigned nurse, but the Administrator confirmed that these sheets are not part of the medical record, leaving no verification that the resident received a shower.
Failure to Inform POA Prior to Diagnostic Procedure
Penalty
Summary
Facility staff failed to fully inform the Power of Attorney (POA) of a resident prior to conducting a diagnostic procedure. The resident, who was under hospice care and had a history of a possible left knee disarticulation, was noted by a nurse to have significant changes and visible pain in the affected leg. Although the hospice nurse had previously discussed the situation with the POA, who declined an X-ray and opted for comfort care, facility staff later ordered and performed an X-ray without documented evidence of further discussion with the POA regarding this change in care. Documentation reviewed by the surveyor showed conflicting notes regarding the POA's wishes, with one entry stating the POA declined the X-ray and another indicating the POA was not opposed to X-rays but only to surgical intervention. Interviews with facility staff confirmed that there was no documentation supporting that the POA was consulted before the X-ray was performed, despite the prior refusal. The Assistant Director of Nursing acknowledged that staff were expected to inform providers of the resident's hospice status and the POA's prior decisions, but this was not documented as having occurred.
Resident Medical Information Left Unprotected in Hallway
Penalty
Summary
Facility staff failed to protect the privacy of residents' medical information on one of three nursing units observed during a complaint survey. A cart was left unattended in the hallway with a laptop displaying patient information and a paper listing medical details for 11 residents, including their MOLST status, diet, and medications. The information was visible to anyone passing by. The surveyor observed the cart for seven minutes while the nurse was inside a resident's room, during which time someone walked by and could have seen the exposed information. When questioned, both the Assistant Director of Nursing and the LPN responsible for the cart acknowledged that resident information should not be left visible and uncovered. The LPN explained that she left the cart to attend to a resident who was leaning in a way she did not like, but during this time, the surveyor noted that the nurse and resident were calmly conversing about daily tasks. The Nursing Home Administrator was informed of the situation and acknowledged understanding of the concern.
Failure to Update Care Plan After Resident Injury
Penalty
Summary
Facility staff failed to revise the interdisciplinary care plan to accurately reflect interventions for a resident who sustained bruises of unknown origin. The resident was found to have bruises on both arms, which, after investigation, were determined to be caused by the resident's arms coming into contact with wheelchair brake extenders while self-propelling. The initial evaluation indicated the resident required assistance but was able to self-propel the wheelchair, and a subsequent therapist assessment confirmed that self-propelling with an extended brake was beneficial for the resident. Despite documenting the incident and the therapist's findings in progress notes, the facility did not update the resident's care plan to address the risk of bruising from the wheelchair brake extenders. During interviews, facility leadership confirmed that while interventions were documented in progress notes, they were not incorporated into the care plan. This omission resulted in the care plan not reflecting the resident's current risk factors and necessary interventions following the incident.
Failure to Provide Required Assistive Devices for ADL Independence
Penalty
Summary
The facility failed to provide necessary assistive devices to a resident with Parkinson's disease and other significant medical conditions, resulting in the resident not having access to built-up utensils and a plate guard during meals. The resident's care plan and the facility's Dining Details Report both specified the need for built-up utensils and a plate guard to maximize independence with eating. However, during observation, the resident was found eating lunch in bed with standard utensils and without a plate guard, despite having sliced peaches that required a fork. The required adaptive equipment was found stored in the resident's dresser drawer, not in use at the time of the meal. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's assistive device needs. The Geriatric Nursing Assistant was unsure of the current requirements, and the Assistant Director of Nursing confirmed that the necessary devices were not in use during the meal observation. The absence of these devices was only addressed after surveyor intervention, indicating a lapse in ensuring that assistive devices were consistently provided as outlined in the resident's care plan and documented needs.
Failure to Provide Prescribed Nutritional Supplements per Care Plan
Penalty
Summary
The facility failed to provide nutritional supplements as documented in a resident's care plan and Dining Detail. Specifically, a resident with diagnoses including Parkinson's with dyskinesia, dementia, dysphagia, and chronic pain was not given prescribed supplements such as vanilla ice cream and mashed potatoes with gravy (super spuds) with lunch and dinner, as well as in-house shakes at 2 p.m., despite these being clearly outlined in both the care plan and the Dining Details Report. The care plan had been updated multiple times to reflect the resident's preferences and nutritional needs, including the removal of ice cream at breakfast per the resident's wishes, and the continuation of ice cream and super spuds with lunch and dinner, along with a daily shake. During the survey, direct observation of the resident's lunch revealed the absence of both super spuds with gravy and vanilla ice cream, with only a sandwich, a drink, and sliced peaches present. Interviews with staff confirmed that these supplements were not provided at the observed meal. The Assistant Director of Nursing also verified that the required items were missing from the resident's meal tray, acknowledging the concern. The deficiency was identified through review of the complaint, medical record, care plan, and direct observation.
Failure to Coordinate and Document Hospice Care Communication
Penalty
Summary
The facility failed to coordinate care for a resident who was receiving hospice services, resulting in a lack of communication and documentation between facility nursing staff and the hospice team. The resident developed swelling, redness, and pain in the left knee, which was initially diagnosed as cellulitis and treated with antibiotics and ibuprofen. Over time, the resident's condition worsened, with further swelling and pain noted. A hospice nurse assessed the resident and suspected a possible disarticulation (fracture vs. dislocation), discussed the situation with the resident's spouse, and decided not to send the resident to the hospital. However, this assessment and decision were not communicated to the facility nursing staff, who later noted a possible dislocation without knowledge of the hospice nurse's previous findings. Interviews with facility staff revealed that communication with hospice staff was primarily verbal and not formally documented. Hospice staff maintained their own paper documentation, which was not routinely shared or reviewed by facility staff. The facility's leadership confirmed that there was no documentation to show that the facility nursing staff acknowledged or discussed the hospice nurse's assessment and the decision made with the resident's power of attorney. This lack of coordinated communication and documentation led to a deficiency in the provision and coordination of hospice care for the resident.
Failure to Document Abuse Training for Care Associate After Suspension
Penalty
Summary
The facility failed to document that a Care Associate (CA) received abuse training after returning from suspension related to an allegation of abuse. The incident involved a resident with dementia and a history of confusion, who alleged that the CA pushed and pulled him and unplugged his television. The CA denied the allegations, and interviews with other staff and residents did not corroborate the claim. The resident was assessed and found to have no pain, and an X-ray showed no acute injury. The investigation concluded that the allegation of abuse was not verified. Despite the outcome of the investigation, a review of the CA's personnel record revealed that there was no documentation of abuse training being completed after the suspension and prior to the CA returning to work. The Nursing Home Administrator confirmed that abuse training is required before returning to work following an abuse allegation, but acknowledged that the required training had not been completed or documented for this CA.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in multiple incidents involving several residents. One significant incident involved an altercation between two residents, where one resident with a history of severe dementia and aggressive behavior entered another resident's room, leading to a physical confrontation. The aggressive resident, who had been readmitted to the facility with a private duty aide, was not consistently supervised, and the facility lacked proper documentation of the aide's presence. This lack of supervision and documentation contributed to the incident where the aggressive resident pushed another resident, causing injuries. Another incident involved a resident being left on a bedpan for an extended period without follow-up assistance, leading to discomfort and neglect. The care associate responsible for this neglect was identified and subsequently terminated. The facility's investigation revealed that the care associate had placed the resident on the bedpan and then attended to other duties, neglecting to check back on the resident in a timely manner. Additional incidents of abuse were reported, including a staff member refusing to care for a COVID-positive resident, resulting in the resident missing a meal, and another staff member providing rough incontinence care despite the resident's complaints of pain. These incidents highlight a pattern of inadequate care and supervision, as well as a failure to ensure residents' safety and well-being, leading to substantiated allegations of abuse and neglect.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to a resident with a documented history of wandering, agitation, and physically aggressive behaviors, resulting in an altercation with another resident. The resident, who had severe cognitive impairment and a history of aggression, was readmitted to the facility after a hospital stay. Despite the known risks, the facility did not consistently ensure the presence of a Private Duty Aide (PDA) to supervise the resident, particularly during critical times when the resident's agitation was known to increase. The resident's medical records indicated a pattern of aggressive behavior, including wandering into other residents' rooms and physical altercations. The facility's care plan included supervision and redirection strategies, but these were not effectively implemented. Staff interviews revealed that the PDA was not consistently present, and there was a lack of documentation regarding the PDA's schedule and presence. This inconsistency in supervision contributed to the incident where the resident entered another resident's room, leading to a physical altercation and injury. The facility's investigation acknowledged the lack of consistent supervision and the failure to document interventions adequately. Staff were aware of the resident's aggressive tendencies, yet the necessary precautions were not consistently in place. The incident occurred during a shift change, highlighting the need for continuous supervision, which was not provided. The facility's documentation and communication regarding the resident's care and supervision were insufficient, contributing to the deficiency.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility staff failed to monitor and implement interventions to address the nutritional needs of residents experiencing significant weight loss. This deficiency was evident in five residents, with Resident #127 experiencing harm due to the lack of timely dietary interventions and consistent weight checks. Despite being aware of Resident #127's significant weight loss through emails and documentation, the facility staff did not take corrective actions promptly. The resident lost over 50 pounds between November 2023 and January 2024, and the facility failed to implement dietary interventions or conduct consistent weight checks. Resident #22 experienced a significant weight loss of 8.17% over three months, yet there were no provider notes addressing this change in condition until much later. The resident's meal ticket indicated the need for assistance with eating and specific dietary supplements, but observations showed that the resident did not consume much of the provided meals. Despite notifications to medical staff and the resident's representative, there was a delay in addressing the weight loss and implementing additional interventions. Resident #17, who had a history of significant weight loss, was not reweighed promptly after being readmitted to the facility. The facility failed to follow through with monitoring and assessing the resident's weight loss, despite the dietician's practice of sending updates to the medical and administrative teams. Similarly, Resident #40 experienced a 10% weight loss in a short period, but the facility delayed implementing interventions and updating the care plan. Resident #33 also experienced significant weight loss, with delays in notifying the physician and implementing measures to address the issue.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the state agency, OHCQ, within the required timeframes. This deficiency was identified for all 16 residents selected for abuse investigation. The facility's policy mandates that such incidents be reported within two hours for the initial report and within five working days for the final report. However, multiple incidents were reported late, with some initial reports being submitted several hours after the required timeframe and final reports being delayed beyond the five-day limit. Specific cases highlight the facility's non-compliance. For instance, Resident #120 was found with a fracture of unknown origin, and the incident was reported to the state agency several hours after the discovery. Similarly, Resident #92's injuries were reported late, and the Director of Nursing mistakenly believed there was a 24-hour window for reporting. Other residents, such as Resident #119 and Resident #66, also experienced delays in reporting their respective incidents to the state agency. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed the lapses in timely reporting. The facility's abuse policy clearly states the requirement for immediate reporting, yet there was a history of non-compliance. Staff members were reportedly educated on the importance of timely reporting, but the facility continued to struggle with adhering to the mandated timeframes, as evidenced by the numerous incidents of late reporting documented in the surveyor's findings.
Deficiencies in Kitchen Food Storage and Preparation Practices
Penalty
Summary
During an initial tour of the kitchen, several deficiencies were identified concerning food storage and preparation practices. An unlabeled opened cooking oil container was found on the shelf in the dry kitchen, and a cook was observed handling and preparing food without wearing gloves and without practicing hand hygiene before putting on gloves. A full container of prepared soup was covered with plastic but lacked a date label. Expired food items, including cooked stuffed cabbage, ground beef, cheese, and burgers, were found in the freezer, and the Certified Dietary Manager was seen discarding these items upon being informed. Additionally, the sanitizer test strips for the three-compartment sink were wrapped in aluminum foil, obscuring the expiration date, and the sanitizer log was incomplete for several days. The dish machine temperature log was also incomplete, with missing documentation for several days, yet dishes were being processed through the machine. Lastly, there was ice buildup observed in the walk-in freezer located in the hallway outside the kitchen. These concerns were communicated to the Certified Dietary Manager during the tour.
Improper Turning Technique Leads to Resident Bruising
Penalty
Summary
The facility failed to treat a resident with dignity by improperly turning them, which was evident in one of the nine residents reviewed for dignity. During an interview, the resident recalled an incident involving a staff member but could not remember the name. The facility reported an allegation of physical abuse after a Geriatric Nursing Assistant (GNA) noticed multiple bruises on the resident's arms. Upon investigation, GNA #66 admitted to using the resident's arms to turn them in bed instead of using a draw sheet. At the time of the incident, the resident was on Aspirin as a blood thinner to prevent blood clots.
Failure to Accommodate Dietary Needs
Penalty
Summary
The facility failed to accommodate the dietary needs of a resident, as observed during a survey. The resident's meal ticket indicated that they required assistance with opening containers and cutting food, as well as specific dietary supplements including a milkshake and ice cream. During an observation, the resident was seen eating lunch in bed with a meal tray that included an uncut sandwich, a drink, a mixed fruit bowl, and a closed container of ice cream. The resident was later observed sleeping with the meal tray still in front of them, with the sandwich only partially cut, the ice cream container unopened, and the fruit cup untouched. The resident's care plan confirmed the need for assistance with opening containers and cutting food, which was not provided, leading to the deficiency.
Failure to Timely Report and Suspend Alleged Abuser
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, resulting in the alleged perpetrator continuing to provide care to the victim before the investigation began. This deficiency was identified during a recertification survey for one resident out of eight reviewed for abuse. On June 8, 2024, a resident informed an LPN that they were mishandled by a Care Associate (CA) during care. The LPN conducted a physical assessment and reported the incident to a supervising RN. However, the report to the state agency was not submitted until the following day, June 9, 2024. Despite the facility's policy requiring immediate suspension of the alleged perpetrator, the CA continued to work with the resident throughout the morning shift on the day of the incident. The administrator confirmed that the CA worked a double shift and was only reassigned during the evening shift. This failure to suspend or reassign the CA immediately after the allegation was reported allowed the alleged perpetrator to remain in contact with the resident, contrary to the facility's stated procedures.
Failure to Sign Medication Record After Antibiotic Administration
Penalty
Summary
The facility staff failed to adhere to professional nursing standards by not signing the medication record after administering an antibiotic to a resident. This deficiency was identified during a survey when a review of the electronic medical record (EMR) showed that a resident was prescribed antibiotic therapy, but the medication was initially unavailable. An alternative antibiotic was ordered and administered by a nurse, as noted in the nursing documentation. However, the nurse did not sign off on the medication record to confirm the administration of the antibiotic. Interviews with the Assistant Director of Nursing and another registered nurse confirmed that the expectation is for nurses to sign the medication record after giving medications to residents.
Failure to Administer Antibiotic Therapy as Ordered
Penalty
Summary
The facility staff failed to administer antibiotic therapy as ordered for a resident who was admitted with a known infection of the right prosthetic hip. The resident was prescribed Cefazolin 2 grams intravenously every 8 hours for 6 weeks. However, the medication administration record revealed that the first dose of the antibiotic therapy was not given as scheduled. A note by Nurse #78 indicated that the prescribed IV antibiotic was not available, but an alternative antibiotic was ordered and available in the Omnicell medication dispensing machine. Further review showed that the resident received Ceftriaxone 1 gram IV at 2 am, but this was not signed off on the medication administration record. Additionally, the resident missed another dose of the antibiotic therapy later that day. The surveyor and the Assistant Director of Nursing verified that the resident missed two doses of the prescribed antibiotic therapy. During an interview, the ADON explained that the nursing management team monitors the medication exception report weekly and reviews notes in the system to verify medication administration.
Lack of Documentation for Resident Shower
Penalty
Summary
The facility staff failed to provide documentation verifying that a resident received a shower during their admission. This deficiency was identified during a survey when reviewing the records of one resident. During an interview, the Director of Nursing explained that a shower/skin sheet is typically completed by the Geriatric Nursing Assistants, who give the resident a shower, and the assigned nurse, who assesses the resident's skin and documents the shower on the form. However, the Administrator confirmed that the resident's skin sheets are not part of the medical record, and there was no documentation available to verify that the resident received a shower.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Parkville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Parkville | 2.9 mi | ★★★★★ | 18 | 0 |
| Autumn Lake Healthcare At Loch Raven | 2.9 mi | ★★★★★ | 34 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 3.1 mi | ★★★★★ | 17 | 0 |
| Franklin Woods Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Overlea | 3.4 mi | ★★★★★ | 5 | 0 |
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