Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Helia Healthcare Of Olney during CMS and state inspections, most recent first.
Menu Not Followed as Planned: A resident council complaint and staff interviews showed the facility did not serve the planned lunch menu on multiple days. Meals were substituted when ingredients were unavailable, including chicken patties instead of chicken breast supreme, meatballs without the planned sauce, and rosemary potatoes instead of company potatoes. Staff stated deliveries were late, items were not ordered in time, and available foods were used to feed the census.
Meal substitutions were not consistently available or appealing during lunch service. Staff served the planned meal items, but residents and the Culinary Assistant confirmed that alternate choices were generally limited to a beef patty, chicken salad sandwich, or leftovers, with no regular substitute vegetable or bread option. Multiple alert and oriented residents stated that alternate selections were not routinely offered and that the food was generally not good, despite the facility policy requiring appealing alternate options of similar nutritive value at all meals.
Kitchen sanitation and dish machine sanitizer testing deficiencies: During a kitchen walk-through, surveyors observed dirt and debris under stainless-steel tables and heavy grease, dust, and old food buildup on the stove/oven surfaces. The dish machine initially had no sanitizer registering on chlorine test strips, and staff stated they were unsure when sanitizer was tested, who serviced the machine, or how to check the sanitizer level; one staff member used pool and spa test strips, and another said the strips in use may have been expired.
Cold Meal Temperatures: A resident who ate meals in her room stated food was often cold when delivered, and several other alert and oriented residents reported the same concern in resident council meetings. During meal delivery, trays were placed on a non-insulated open-to-air cart, and a test tray delivered to a resident room showed food temperatures of 109.4°F for chicken, 94.2°F for potatoes, and 88.5°F for carrots; another resident stated her lunch was cold, and an Activities staff member said residents had complained about food temperatures.
Failure to Serve Mechanical Soft Diets With Ordered Gravy or Sauce: The facility served mechanical soft meals to residents without the ordered gravy or sauce on meats. A Culinary Assistant confirmed no gravy was prepared for one meal, and another staff member was observed draining sauce off meatballs before plating them. One resident with dysphagia, cerebral ischemia, and other significant diagnoses had physician orders for a mechanical soft diet with gravy on meats, yet was served chicken patty and meatballs without gravy or sauce. The CNA, MDS Coordinator, SLP, RD, and Administrator all acknowledged the expectation that mechanical soft meats should be served with gravy or sauce.
A resident with RA, asthma, HF, HTN, and DM had a cognitively intact status per BIMS, yet her shower continuously ran water for months and black substance was observed on the shower floor near the drain. The resident said she had already reported the issue to Maintenance, an LPN said a work order had been submitted, and Maintenance acknowledged awareness of the problem and needing a new cartridge, but the work order could not be located.
Failure to provide recommended ROM program: A resident with CVA-related R hemiplegia/hemiparesis and limited UE ROM was discharged from OT with a restorative UE ROM program, but the care plan did not reflect restorative nursing needs and the MDS indicated no restorative nursing was provided. The resident stated she did not receive arm or leg exercises, and staff interviews showed the COTA expected the program to be implemented while the DON was unaware of the recommendation.
A dependent, medically complex resident who required extensive assistance and mechanical lift transfers was repositioned in a recliner by two CNAs who lifted under the resident’s arms and grabbed the waist/pants without using a gait belt, contrary to facility safe patient handling and gait belt policies. During this maneuver, several loud pops were heard from the resident’s left arm and the resident immediately reported that the arm was broken; subsequent x‑ray confirmed an acute proximal humerus fracture suspected to be pathological. The initial RN notified of the event did not assess the resident or report the incident at shift change, leaving the resident without timely nursing evaluation. Later assessment documented pain with movement and decreased ROM, and family and staff reported the resident experienced severe pain through the night and next morning, while only acetaminophen was initially available and nurses described difficulty obtaining ordered opioid analgesia from the pharmacy and on‑call MDs. The attending MD later stated that, given the resident’s weakened condition and lack of gait belt use, the repositioning most likely caused the fracture and that the facility could have provided better care.
A resident with multiple chronic conditions sustained an acute left humerus fracture when two CNAs lifted the resident in a recliner by the arms without a gait belt, resulting in audible pops and immediate complaints that the arm was broken. The CNA reported the incident to an RN, who failed to assess the resident or notify the oncoming nurse. Later, another RN assessed the resident, noted significant pain with movement, obtained an x-ray order, and administered PRN acetaminophen, while a family member reported the resident was in horrible pain and that requests for stronger pain medication were met with comments about the difficulty of obtaining narcotics. Overnight, pain assessments were incomplete or undocumented, and pain was charted as zero despite guarding and reported pain. The next morning, another RN documented pain at 10/10, gave acetaminophen with little effect, and obtained an order for hydrocodone-acetaminophen, but due to delays in pharmacy access and e-prescribing, the narcotic was not administered for several hours, during which the resident continued to experience severe pain, contrary to the facility’s pain assessment and management policy.
A resident with multiple chronic conditions sustained a left humerus fracture during repositioning and subsequently experienced severe pain. Staff had only PRN acetaminophen ordered and available that night, did not obtain stronger analgesia from the pharmacy or e‑kit, and the resident remained in significant pain until the next day when hydrocodone‑acetaminophen was finally accessed from the e‑kit after delay. The resident’s scheduled evening and morning medications were not available due to late pharmacy delivery, and staff did not request STAT delivery or use the e‑kit for commonly used drugs. An RN documented several morning medications as administered on the eMAR even though they were not given, later stating the system would not allow correction, and leadership and the pharmacist acknowledged ongoing problems obtaining narcotics and new‑resident medications despite policies for 24/7 emergency pharmacy service and e‑kit use.
Two residents with behavioral health diagnoses were involved in a physical altercation, during which one resident struck another multiple times with a closed fist, and the other resident responded by grabbing the first resident's arm. Staff separated the residents and assessed them for injuries, finding none. The incident was reported to the administrator, physician, and authorities, and was documented in the medical records. The event occurred despite existing behavioral care plans and interventions intended to prevent such incidents.
A medication cart was left unlocked and unattended with its keys on top and out of visual control by an RN during medication pass, while confused, ambulatory residents were present. Facility policy requires medication carts to be locked and keys to remain with licensed staff, but this was not followed, allowing unauthorized access to medications.
A resident with cognitive impairments and multiple medical conditions sustained a burn from spilling hot coffee on her thigh. The facility failed to consistently monitor coffee temperatures, with logs showing gaps and inconsistencies. The coffee was served without a lid, and the resident accidentally spilled it while talking to another resident. The incident was partly attributed to the resident's medication, which caused drowsiness, and highlighted a lack of safety measures for handling hot beverages.
The facility failed to ensure dishware was sanitized appropriately, potentially affecting all 66 residents. A dietary aide used swimming pool test strips to check the dish machine sanitizer, which read very high. The dietary manager, new to the position, found the correct test strips, revealing a sanitizer level below the required 50 ppm. The manager admitted to not considering alternative sanitization methods.
The facility failed to provide correct food portions as per the approved menu for four residents. During lunch service on two separate days, the cook served significantly smaller portions than specified in the facility's recipes and menus. The dietary manager confirmed that all residents should receive the portion sizes listed on the menu or recipe unless otherwise directed by the registered dietitian or physician, which was not adhered to in these instances.
The facility failed to provide nutritional supplements as ordered for two residents. One resident with a complex medical history did not receive her prescribed nutritional shake during lunch, and the Dietary Manager confirmed the facility had run out of shakes. Another resident with severe protein-calorie malnutrition also did not receive her prescribed nutritional health shake, and the cook confirmed insufficient supply. This highlights a lapse in adherence to dietary protocols.
Menu Not Followed as Planned
Penalty
Summary
The facility failed to ensure the planned menu was provided to residents. On 5/19/26, the lunch menu on the week-at-a-glance plan listed chicken breast supreme, carrots, green beans, and peach slump cake, but residents were served a chicken patty or beef patty, corn, green beans, and cake with whipped topping. A Culinary Assistant stated the chicken thighs had not been taken out of the freezer the night before, there was not enough time to thaw and cook them, and she substituted chicken patties and beef patties. She also stated the planned peach slump cake was altered by adding crushed canned peaches to the cake mix. On 5/20/26, the planned lunch menu listed meatballs with a sweet and savory sauce, rice, and green peas, but residents were served meatballs without sauce, white rice, and green beans mixed with green peas. A Culinary Assistant stated she used teriyaki sauce and orange marmalade to make a sauce because that was all she had available, and she added green beans because she would have run out of vegetables. The Culinary Manager stated the food truck had been arriving later than usual for the past few weeks, that the facility had to buy meatballs and peas from a local grocery store, and that not enough peas were purchased so green beans were added to feed the entire census. On 5/21/26, the planned lunch menu listed savory baked chicken, company potatoes, garden seasoned carrots, and chef's choice of dessert, but residents were served baked chicken thighs, rosemary potatoes, seasoned carrots, and cake because the company potatoes were not made due to not having enough fresh baking potatoes. During resident council, a resident stated the facility did not always follow the menu and residents did not know what would be served.
Meal Substitutions Not Available or Appealing
Penalty
Summary
The facility failed to offer meal substitutions that were appealing and of similar nutritive value to residents during meal service. On 5/19/26 at lunch, a chicken patty, green beans, carrots, and peach cake were served instead of the planned chicken supreme, carrots, peach slump cake, and green beans. The Culinary Assistant stated there was a beef patty for residents who did not want chicken, but no alternative to the vegetable and no bread was served. During the same meal, a resident who was alert to person, place, and time stated that carrots or green beans are often served at lunch and dinner and that alternate meal selections are never available, other than a chicken salad sandwich or leftovers from the previous meal if any remain. On 5/20/26 at lunch, meatballs, white rice, green peas mixed with green beans, and apple pie were served, and no other food items were available on the steam table. The Culinary Assistant stated she did not make any alternative food choices, but could make a chicken salad sandwich if a resident did not like the meatballs. During the resident council meeting that day, multiple alert and oriented residents confirmed that alternate meal options for the main choice or vegetable were not regularly available, that the food was generally not good, and that they did not eat much from their plates. On 5/21/26 and 5/22/26, lunch service again showed only the main meal items on the steam table, and staff confirmed there were no substitutions available other than chicken salad sandwiches after tray line was complete. The facility policy dated 12/2016 stated that appealing alternate options of similar nutritive value should be available for all meals, including an alternate entree and vegetable at lunch and dinner, but this was not consistently done.
Kitchen sanitation and dish machine sanitizer testing deficiencies
Penalty
Summary
Proper sanitation of dishes and cleanliness of kitchen equipment were not maintained to prevent cross contamination. During the initial kitchen walk-through, dirt and debris were observed under the floor-mounted stainless-steel tables, and the oven/stove had a layer of grease and dust buildup on the top shelf over the stove, the backsplash, sides, oven doors, and oven top, along with old food splatters and dried spills. The dish machine had no sanitizer registering on the chlorine test strips, and a Culinary Assistant stated she was unsure when the machine was tested for sanitizer other than once a month when a service person came in. Another Culinary Assistant stated he was the main dish washer but did not regularly test the sanitizer level and was not aware that he should be doing so. Staff further stated they were unsure how to test the sanitizer level and were unsure who serviced the dish machine. One staff member believed the chlorine test strips may have been outdated, while the Maintenance Director used pool and spa test strips and stated those were the strips he had been told to use. The dish machine was not in use when the sanitizer level was not within the manufacturer recommended range. Later, after new test strips were obtained from a sister facility, the dish machine was run again and the chlorine level tested within 50-100 ppm. The facility application documented 71 residents, and the kitchen sanitation policy stated the kitchen would be maintained in a clean and sanitary condition and that food service workers would receive training on cross contamination and proper cleaning and sanitizing techniques.
Cold Meal Temperatures
Penalty
Summary
The facility failed to ensure that resident meals were delivered at appetizing and preferred temperatures for 5 of 5 residents reviewed for cold food complaints. During the resident council meeting, R8, who was alert and oriented, stated that food is cold when delivered to her room and that when she is hungry she often has to eat cold food because she chooses to eat most meals in her room. R14, R19, and R44, who were alert and oriented to person, place, and time, stated they had complained about food temperatures in resident council meetings. On 5/21/26, R8 stated that her breakfast tray arrived with cold eggs and French toast and that she did not eat very much of it. During lunch delivery that same day, Arch unit trays were loaded on a non-insulated open-to-air cart with plastic domes over the plates; the cart left the serving window at 11:13 AM and the test tray was not delivered until 11:40 AM. At that time, the measured temperatures were 109.4 degrees Fahrenheit for chicken, 94.2 degrees Fahrenheit for potatoes, and 88.5 degrees Fahrenheit for carrots. R73, who was alert and oriented to person, place, and time, stated her lunch was cold and was observed eating in her room. V7 from Activities stated residents do complain about food temperature in resident council meetings, but review of the last 12 months of grievances and resident council minutes found nothing regarding cold food complaints.
Failure to Serve Mechanical Soft Diets With Ordered Gravy or Sauce
Penalty
Summary
The facility failed to ensure residents received food items in accordance with physician-ordered mechanical soft diets with gravy or sauce on meats. During lunch meal service, ground chicken patty was observed being served to residents on mechanical soft diets without gravy, and no gravy was available on the steam table. V4, a Culinary Assistant, confirmed that no gravy had been made for that meal, and no menu or recipe was available for the item because it was not planned. In another observation, the recipe for meatballs sweet and savory ground directed staff to serve the meatballs with 2 fluid ounces of sweet and savory sauce, with additional sauce as needed to moisten the meat, but V5, a Culinary Assistant, was observed placing the meatballs in a slotted spoon and allowing the thin sauce to drain off before plating them. R53’s record showed diagnoses including cerebral ischemia, adult failure to thrive, chronic pulmonary edema, pulmonary fibrosis, heart failure, paroxysmal atrial fibrillation, and dysphagia, oral phase. R53 had physician orders and dietary documentation for a mechanical soft diet with gravy on meat, and was observed receiving chicken patty and later sweet and savory meatballs without gravy or sauce. V14, a CNA, stated R53 should have gravy or sauce on her meat for each meal because of swallowing issues, and V6, the MDS Coordinator, stated R53 was supposed to have gravy on her meats because she had been choking on food in the hospital before admission. The Administrator stated the expectation was for staff to follow dietary orders, while the Speech Pathologist and Registered Dietitian stated mechanical soft meats should have gravy or sauce to aid swallowing. The facility’s diet type report showed that 18 residents, including R4, R6, R13, R14, R16, R21, R22, R26, R27, R29, R34, R35, R45, R47, R52, R53, R64, and R65, were ordered mechanical soft diets.
Resident Shower Left Running and Not Maintained
Penalty
Summary
The facility failed to ensure resident equipment was maintained in a state of good repair for R58. R58 was admitted on 9/21/2010 with diagnoses including rheumatoid arthritis, mild intermittent asthma, uncomplicated heart failure, essential primary hypertension, and type 2 diabetes mellitus without complications. Her MDS documented a BIMS score of 15, indicating she was cognitively intact. During observation, R58 stated her shower in the bathroom was not working properly and continued to run water, and she reported she had spoken with Maintenance about the issue previously. At the time of observation, the shower head was continuously running water at a medium flow into the shower, and black substance was noted on the shower floor in front of the drain. The same condition was observed again the next day, with the shower head still continuously running water at a medium flow and scattered black substance on the shower floor in front of and around the drain. An LPN stated staff complete work orders for items not working properly and believed a work order for R58's shower had been submitted about 2 weeks earlier. Maintenance stated staff submit work orders for broken items, but he could not locate the work order and said he believed he first received it about 2 months earlier. Maintenance also stated he was aware the shower continuously ran water and that he had notified Administration about needing a new cartridge for the shower. A CNA who provided direct care to R58 stated the shower had gone from a trickle to continuously running a moderate amount of water over the prior 3 to 4 months, that a work order had been turned in, and that black substance had been noticed on the shower floor.
Failure to Provide Recommended ROM Program
Penalty
Summary
The facility failed to provide a range of motion program per COTA recommendations for one resident with limited ROM. The resident, admitted on 01/23/2025, had diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right side, speech and language deficits following cerebral infarction, chronic kidney disease, and insomnia. The resident’s current care plan did not document problem areas related to the right arm/hand hemiplegia and hemiparesis requiring restorative nursing, and the quarterly MDS coded an upper extremity ROM impairment while also indicating the resident did not receive restorative nursing. The OT discharge summary documented restorative programs, including a restorative ROM program for the upper extremity. During observation, the resident was sitting in a wheelchair in her room, stated she did not receive exercises on her arms or legs, and her right arm was observed lying in her lap with her fingers curled in. The COTA stated the resident was discharged with a program for upper extremity ROM and expected the facility to put a program into place if recommended. The DON stated ROM is not a program the facility usually places for residents and was not aware OT had recommended a restorative ROM program, while the Administrator stated it was her expectation that nursing would put the program in place when therapy recommended it.
Improper Repositioning Without Gait Belt Causes Humerus Fracture and Poor Pain Control
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer and reposition a dependent resident in accordance with its own safe patient handling and gait belt policies. The resident had multiple serious diagnoses, including COPD, diabetes, CHF, small cell B lymphoma, and hypertension, and was assessed on admission as not independent in transfers or ambulation, not predictable or cooperative, unable to bear weight, and requiring a full-body mechanical lift for all transfers. A functional abilities assessment documented that sit-to-stand was not attempted due to medical or safety concerns and that bed mobility required substantial/maximal assistance. Nursing documentation described the resident as a “heavy 2 assist,” very weak, and incontinent, with an indwelling catheter and a stage 2 pressure sore. On the day of the incident, family requested that staff pull the resident up in his recliner because he was sliding down. Two CNAs (V3 and V4) stood on either side of the recliner and, without using a gait belt, hooked their arms under the resident’s armpits and used their other hands to grab the resident’s waist/pants to lift and pull him up in the chair. During this maneuver, multiple witnesses, including family and staff, reported hearing three loud pops from the resident’s left arm, after which the resident stated that his arm was broken. The resident then had minimal movement below the elbow and was unable to move the arm above the elbow without serious pain. The facility’s Safe Patient Handling Policy required use of lift equipment and/or assist devices for residents who were totally dependent or required extensive assistance, and the DON stated that repositioning in a situation such as this required use of a gait belt. The Gait Belt Use Policy required gait belts when staff transfer weight-bearing residents or assist with walking, and the therapy director stated that current recommendations for a similar resident would be repositioning with a gait belt rather than lifting under the arms. Following the incident, there were additional failures in timely assessment and pain management. CNA V3 immediately reported the event to the RN on duty (V5), who stated she would assess the resident after finishing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse. V3 continued to check the arm every 10 minutes for swelling or bruising, but no nurse assessment occurred before shift change. The oncoming RN (V6) was informed by V3 about the popping noise and the resident’s pain and then assessed the resident, noting pain with movement and decreased range of motion but no swelling or bruising. A portable x-ray was ordered and later showed an acute proximal left humerus fracture suspected to be pathological. Family and staff reported that the resident experienced severe pain that evening and into the next morning, with family describing “horrible pain,” moaning, and screaming with repositioning. Initially, only Tylenol was administered despite reports of severe pain, and both night and day shift nurses (V7 and V8) described difficulty obtaining narcotic pain medication from the pharmacy and on-call physicians. The primary care physician later stated that, in the resident’s weakened state and without a gait belt, the repositioning most likely caused the fracture and that the facility could have done a better job of taking care of the resident.
Failure to Promptly Assess and Adequately Manage Severe Pain After Arm Fracture
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and adequately manage severe pain for a resident who sustained an acute left humerus fracture. The resident was a recent admission with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, hypertension, prostate cancer, and lymphoma. On the afternoon of admission, two CNAs repositioned the resident in a recliner by placing their arms under the resident’s armpits and lifting without a gait belt. During this maneuver, three loud pops were heard from the resident’s left arm, and the resident immediately stated that the arm was broken. A family member present confirmed hearing a loud crack and reported that the resident said, “You broke my arm.” The CNA promptly reported the incident to the RN on duty (V5), who stated she would assess the resident after completing a medication pass but then forgot, did not assess the resident, and did not report the incident to the oncoming nurse. Later that evening, the oncoming RN (V6) was informed by the CNA that there had been a popping noise from the resident’s arm during repositioning and that the resident was in pain. V6 assessed the resident and noted that the left arm was not bruised or swollen and was not painful if immobile, but there was significant pain with movement and decreased range of motion. V6 contacted the on-call physician (V9), who ordered a portable x-ray, and administered two Tylenol tablets around 7:00 p.m. per an existing PRN order. The family member reported that as the evening progressed, the resident was in “horrible pain,” moaning and screaming out when repositioned, and that Tylenol was not given until sometime around 9:00 p.m. The family member also stated that when she requested stronger pain medication, V6 responded that obtaining a narcotic order at that time of day was “a whole big thing.” The x-ray later confirmed an acute, likely pathological, fracture of the proximal shaft of the left humerus. Overnight, the night-shift RN (V7) recalled that the resident was guarding the arm and did not want it moved, but did not recall performing a pain scale or the specific severity of the pain, and was unsure if Tylenol was administered during her shift. The MAR documented that Tylenol was given at 9:29 p.m. and again at 6:35 a.m., with no numeric pain ratings recorded and only qualitative notes that it was effective or slightly effective. The facility’s records also showed a standing order for pain assessment every shift, with pain documented as zero on the evening and night shifts, despite reports of significant pain with movement and family observations of severe pain. On the following morning, the day-shift RN (V8) assessed the resident and documented a pain level of 10/10. Tylenol was administered around 6:30 a.m. with little effect, and V8 contacted the primary care physician (V10), who ordered hydrocodone-acetaminophen PRN. Due to limitations in e-prescribing and pharmacy access, the narcotic was not administered until after 10:30 a.m., during which time the resident continued to experience severe pain. Staff interviews indicated that nurses perceived obtaining narcotic pain medications, especially at night and for new residents, as difficult, and this contributed to delays in escalating pain management beyond Tylenol. The facility’s own Pain Prevention and Treatment Policy required that each resident be assessed for pain using an appropriate pain rating scale upon admission and at least quarterly, and that after completion of the assessment, residents receive interventions to reduce or alleviate pain, including pharmacological interventions with a physician’s order. The resident’s MDS pain assessment documented that in the last five days the resident rarely or not at all experienced pain, and that the worst pain over the last five days was rated as 4, which did not reflect the documented 10/10 pain level and severe pain behaviors described after the fracture. The MAR lacked numeric pain ratings associated with PRN pain medication administration and showed a pain score of zero on shifts when the resident was reported to have significant pain with movement. These actions and inactions—including failure to promptly assess the injury when first reported, failure to consistently and accurately assess and document pain using a numeric scale, and delays in obtaining and administering stronger pain medication—resulted in the resident experiencing severe pain for approximately four hours after sustaining the fractured left humerus.
Failure to Provide Timely Pain Control, Routine Medications, and Accurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely routine and emergency medications and to accurately document medication administration for a resident with multiple serious diagnoses, including COPD, Type 2 diabetes, CHF, small cell B lymphoma, and hypertension. The resident was admitted with numerous scheduled medications (Eliquis, Lasix, metoprolol, potassium chloride, magnesium oxide, folic acid, vitamin D3, inhaled/nebulized respiratory medications, and others) and PRN Tylenol for pain. On the evening of admission, the resident’s evening medications were not administered because they were unavailable due to delayed pharmacy delivery, and the MAR documented that no scheduled evening medications were given for that reason. The facility did not utilize the emergency medication kit or request a STAT delivery from the pharmacy, despite the pharmacy’s later statement that most commonly used medications and controlled substances were available in the e-kit and that a STAT delivery could have been guaranteed within four hours if requested. During repositioning in a recliner around dinner time, two CNAs lifted the resident without a gait belt, and a popping sound was heard from the resident’s left arm, after which the resident complained of pain and stated his arm was broken. Nursing assessment later that evening documented minimal movement below the elbow, inability to move the arm above the elbow without serious pain, and decreased range of motion, and an on‑call physician ordered a portable x‑ray, which showed a pathological transverse fracture of the left humerus. The only pain medication available and ordered that evening was PRN Tylenol, which was administered around 9:29 p.m. and provided some relief, but the family reported the resident was in horrible pain, moaning, and screaming out with repositioning. Staff did not obtain or attempt to obtain narcotic pain medication from the pharmacy or the e-kit that night, despite the on‑call physician later stating he could have provided an order and that an e‑script could have been used to access narcotics from the e‑kit. The following morning, the resident continued to experience severe pain rated 10/10. The RN on duty administered Tylenol around 6:30 a.m., which was documented as only slightly effective, and contacted the primary care physician, who ordered hydrocodone‑acetaminophen PRN for pain and directed that Eliquis be held pending goals‑of‑care clarification. However, due to the physician not being in his office to e‑script immediately, the facility did not obtain the narcotic from the e‑kit until after 10:20–10:29 a.m., and the resident remained in severe pain until that time. Additionally, the RN documented that several morning medications (Eliquis, magnesium oxide, vitamin D3, folic acid, and Lasix) were charted as given on the electronic MAR but were in fact not administered due to family questions and pharmacy delivery delays; the nurse stated there was no way to uncheck medications once marked as given in the eMAR. The DON and pharmacist confirmed ongoing problems with obtaining narcotics and new‑resident medications from the contracted pharmacy, and the pharmacist confirmed that the facility did not call for e‑kit codes or request STAT delivery for this resident’s medications, despite policy stating that emergency pharmacy service and e‑kit access are available 24/7 and that medications must be administered and documented in accordance with prescriber orders.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an altercation between two residents. One resident, who had diagnoses including dementia with mood disturbances, heart failure, anxiety disorder, and Parkinsonism, and who had a moderate cognitive deficit, was involved in a physical altercation with another resident diagnosed with neuroleptic-induced parkinsonism, bipolar disorder, and schizophrenia, who was cognitively intact. The incident occurred when the second resident, while in her wheelchair, made contact with the first resident using a closed fist to the side and arm. The first resident then responded by making contact with the second resident's arm. Both residents were separated by staff and assessed for injuries, with no marks, bruising, or redness noted. The care plans for both residents documented behavioral symptoms and previous incidents, including inappropriate comments, threats, and prior altercations. Interventions in the care plans included attempts to keep the residents separated and monitoring for behavioral issues. Despite these interventions, the altercation occurred, and staff responded by separating the residents and assessing them for injuries. The incident was reported to the administrator, physician, and other relevant parties, and documentation was made in the residents' medical records. Interviews with staff indicated that the altercation was witnessed by a CNA, who reported it to an LPN, and subsequently to the administrator. The administrator did not witness the event but was informed by staff. The incident was also reported to the police and the state survey agency. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and requires immediate action when such incidents occur.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart was observed left unlocked and unattended on two separate occasions while a registered nurse was passing medications. During these times, the cart keys were left on top of the cart and out of the nurse's visual control. These incidents occurred in the presence of residents and staff, with four confused and ambulatory residents identified as having access to the unsecured medication cart. The facility's policies require that medication carts be kept locked and that keys remain in the possession of the nurse administering medications. Only licensed nursing personnel or those lawfully authorized are permitted to access medication storage areas. The Director of Nursing confirmed that the cart should have been locked and the keys kept by the nurse. The residents involved were documented as confused and ambulatory, increasing the risk of unauthorized access to medications.
Resident Burned by Hot Coffee Due to Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to adequately monitor and control the temperature of coffee served to residents, leading to an incident where a resident sustained a burn. The resident, who has a history of neuroleptic induced parkinsonism, bipolar disorder, schizophrenia, and other medical conditions, spilled coffee on her inner thigh, resulting in a blister. At the time of the incident, the resident was moderately cognitively impaired, as indicated by a BIMS score of 10. The coffee was served without a lid, and the resident was in the dining room when she accidentally spilled the coffee while attempting to talk to another resident. The facility's coffee temperature logs showed inconsistencies, with no temperatures recorded for a week and documented temperatures ranging from 185 to 130 degrees Fahrenheit. The Dietary Manager admitted to confusion and staffing issues that led to the lack of temperature monitoring during that period. The coffee was initially brewed at 205 degrees Fahrenheit and allowed to cool before being served, but the exact temperature at the time of the incident was not verified. The Registered Nurse present during the incident confirmed that the resident dropped the coffee cup, leading to the burn. The Director of Nursing and the Administrator acknowledged that the incident was partly due to the resident's medication, which caused drowsiness. The facility had not previously identified the need for coffee lids or other assistive devices for residents consuming hot beverages. The incident highlighted a gap in the facility's procedures for ensuring the safety of residents when handling hot liquids, particularly for those with cognitive impairments or other risk factors.
Improper Dishware Sanitization
Penalty
Summary
The facility failed to ensure dishware was sanitized appropriately, potentially affecting all 66 residents. On 05/05/24, a dietary aide used swimming pool test strips to check the dish machine sanitizer, which read very high. The dietary manager, who had been in the position for about two months, acknowledged the incorrect test strips and found the appropriate chlorine test strips, which indicated a sanitizer level of approximately 10 ppm, below the required 50 ppm. The dietary manager admitted to not considering alternative sanitization methods and was still learning the role. On 05/06/24, the dietary manager tested the dish machine sanitizer again, and the chlorine test strip indicated an appropriate range of 100 ppm. The facility's policy from 01/2012 requires employees to use appropriate test strips to check sanitizer concentration. The daily census report documented 66 residents residing at the facility, all of whom were potentially affected by the improperly sanitized dishware.
Failure to Provide Correct Food Portions as Per Approved Menu
Penalty
Summary
The facility failed to provide food portions as directed by the approved menu for four residents. Specifically, during lunch service on two separate days, the cook served portions of ground chicken tenders, mashed potatoes, ground Swedish meatballs, pureed chicken, pureed egg noodles, and pureed bread that were significantly smaller than the amounts specified in the facility's recipes and menus. For example, residents were served 2.875 ounces of ground chicken tenders instead of the required 4.75 ounces, and 1.125 ounces of mashed potatoes instead of 3.75 ounces. These discrepancies were observed for residents with various medical conditions, including cerebral ischemia, dementia, type 2 diabetes, chronic kidney disease, protein-calorie malnutrition, and other serious health issues, who had specific dietary orders that were not followed correctly. The dietary manager confirmed that all residents should receive the portion sizes listed on the menu or recipe unless otherwise directed by the registered dietitian or physician, which was not adhered to in these instances. The report highlights that the facility's policy on menus and food preparation, which mandates that meals be prepared according to the approved menu and corresponding recipes, was not followed. This failure was observed through direct inspection and interviews, revealing that the residents did not receive the appropriate portion sizes as per their dietary requirements. The dietary manager acknowledged the discrepancy, stating that all residents should receive the supplements and dietary orders as prescribed, which was not the case during the observed meal services. This deficiency affected the nutritional intake of the residents, potentially impacting their health and well-being.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for two residents, R45 and R56, out of a sample of 40 residents reviewed for nutrition. R45, who has a complex medical history including cerebral ischemia, dementia, and type 2 diabetes mellitus, was observed not receiving her prescribed nutritional shake during lunch. The Dietary Manager (V10) confirmed that the facility had run out of nutritional shakes and acknowledged that nutritional ice creams should have been provided as a substitute. The facility's policy on weight management emphasizes the importance of following physician orders and providing necessary nutritional supplements, which was not adhered to in this case. Similarly, R56, who suffers from severe protein-calorie malnutrition, dysphagia, and other significant health issues, did not receive her prescribed nutritional health shake during lunch. Despite being on a puree diet with supplements, R56 was only served a glass of water and a flavored drink mix. The cook (V13) confirmed that the facility had insufficient nutritional health shakes to meet the needs of all residents with such orders. This failure to provide essential nutritional supplements as ordered highlights a significant lapse in the facility's adherence to dietary and nutritional protocols.
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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 Olney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richland Nursing & Rehab | 0.7 mi | ★★★★★ | 33 | 1 |
| Helia Healthcare Of Newton | 17.2 mi | ★★★★★ | 1 | 0 |
| The Haven Of Bridgeport | 17.5 mi | ★★★★★ | 6 | 0 |
| The Haven Of Ridgeview | 19.6 mi | ★★★★★ | 3 | 0 |
| Axiom Gardens Of Flora | 22 mi | ★★★★★ | 19 | 0 |
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