Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Olney Rehabilitation And Care Center during CMS and state inspections, most recent first.
Food Storage and Warewashing Sanitation Deficiencies: The facility failed to maintain sanitary food service conditions in the kitchen and food storage areas. The liquid soap dispenser at the handwashing sink was empty and dish detergent was being used there, the cabinet doors beneath the sink did not close completely, and the high-temp dish machine was installed but not in use because it kept tripping the breaker. Dietary staff manually washed utensils, cups, pots, pans, and other items in a two-compartment sink, but the Dietary Mgr did not keep logs of water temperatures or bleach sanitizer levels. The kitchen also had missing floor tiles, peeling wooden shelving and cabinets, soiled shelf liner with crumbs and dust, improperly stored open dry food packages, a non-working refrigerator used for paper goods, and a dusty ice machine exterior.
Dish Machine Not Operating and Manual Sanitizing Process Not Properly Established: The kitchen dish machine was not in use because it kept tripping the breaker after installation, and the back legs had been removed so the unit rested on wooden blocks. The Dietary Mgr stated residents were served on paper plates and bowls, while silverware, cups, and kitchenware were washed in a 2-compartment sink with bleach used for sanitizing, no clear rinse sink, and no log of water temps or sanitizer levels.
A facility failed to encode and transmit a Quarterly MDS and a Significant Change MDS for two residents. One resident had DM2, gout, dementia, HTN, and a L leg amputation, while the other had COPD, dementia, and HTN. Both assessments were marked Export Ready but were never sent to CMS, and leadership stated the assessments were still being worked through after a management change and access issues with the MDS system.
Two residents had inaccurate MDS coding. One resident with type 2 DM had an order for weekly sliding-scale NovoLIN R insulin, but the MDS documented daily insulin injections. Another resident with AFib had an order for Clopidogrel, but the MDS coded the medication as an anticoagulant. The VPCR confirmed both entries were inaccurate, and the facility policy required assessments to accurately reflect resident status using the RAI process.
Two residents in an LTC facility were administered insulin without proper priming of the insulin pen, resulting in a medication error rate of 7.69%. The involved LVNs and DON were unaware of the need to prime the pens, leading to potential underdosing of insulin for residents with Type 2 Diabetes Mellitus.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended in hallways. This included a treatment cart with medicated dressings and a medication cart with prescription drugs. LVNs acknowledged their responsibility to lock the carts, and the DON and ADM confirmed the expectation for carts to be secured to prevent unauthorized access.
The facility failed to maintain cleanliness in the kitchen, with spilled dry milk and food crumbs observed in refrigerator #1 and dirt on the kitchen floor. The Dietary Manager, new to the role, did not ensure daily cleaning tasks were completed, as evidenced by missing initials on the cleaning schedule. The Administrator expected daily cleaning to prevent infection and pests, aligning with facility policy and FDA standards.
A resident with dementia and a urinary tract infection received incontinence care from an LVN who failed to change soiled gloves and perform hand hygiene, leading to a breach in infection control protocols. The DON confirmed the expectation for proper infection control techniques, which were not followed according to the facility's procedure manual.
A facility failed to ensure proper documentation of wound care for a resident with a diabetic foot ulcer. Nurses did not initial and date wound dressings, as observed during an interview with an LVN who admitted to forgetting this step. The DON emphasized the importance of this practice to verify wound care was performed. The resident, with a history of diabetes and other health issues, confirmed receiving daily care without pain.
Food Storage and Warewashing Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and related food storage areas. During the initial kitchen tour, the liquid soap dispenser near the handwashing sink was empty and a bottle of dish detergent was being used at the sink. The wooden cabinet doors beneath the sink did not close completely, the high-temperature dish machine had been installed but was not being used because it kept tripping the breaker, and the back of the machine was resting on wooden blocks after the back legs were removed. Dietary staff were manually washing resident eating utensils, beverage glasses, coffee cups, pots, pans, mixing bowls, serving utensils, and other utensils in a two-compartment sink. The Dietary Manager stated detergent and bleach were added to the first sink compartment and bleach was added to the second compartment, but there was no sink used for clear rinse water. She also stated she was not keeping a log of the two-compartment sink water temperatures or bleach sanitizer levels. The floor tiles were missing beneath the dish machine, exposing the concrete floor. Wooden shelves and cabinets throughout the kitchen had scraped and peeling paint with porous wood exposed, and shelf liner was covering some wooden shelving surfaces. In the paper supply closet, shelves covered with textured liner were soiled with dust and food crumbs beneath the liner. The closet contained dry food items including an open bag of bread crumbs twisted closed and dated 8/29/25, an open bag of small elbow macaroni that was not dated and had been knotted closed, an open bag of small egg noodles dated 10/24/25 twisted closed, refried pinto beans in a resealable bag that was not labeled and dated when opened, and a 5-pound bag of white cake mix in a resealable bag dated 8/05. The Dietary Manager stated some of the items were staff food and that she would discard the cake mix and pinto beans. A non-working commercial refrigerator in the office was being used to store paper plates, cups, and plastic cup lids, and the top exterior surface of the ice maker in the hallway was covered with a thick layer of dust.
Dish Machine Not Operating and Manual Sanitizing Process Not Properly Established
Penalty
Summary
The facility failed to ensure that mechanical and electrical equipment in the kitchen was maintained in safe operating condition. During observation, the low temperature dish machine was not operating and was not being used to wash and sanitize resident-use eating utensils, beverage glasses, coffee cups, or food preparation pots, pans, mixing bowls, cooking utensils, and serving utensils. The manufacturer recommendations posted for the dish machine indicated minimum water temperatures of 160 degrees F for washing and 180 degrees F for rinsing, but the machine was not in use at the time of the observation. The Dietary Manager stated a new high temperature dish machine had been delivered and installed about two weeks earlier, but the back two legs had been removed by the Maintenance Director and the back of the machine was resting on wooden blocks. She stated the machine was connected but kept throwing the breaker when operated, so dietary staff were told not to use it until an electrician could come to the facility. She also stated residents were being served meals on paper plates and bowls, while stainless steel silverware, beverage glasses, and coffee cups were still being used. The Dietary Manager stated dietary staff were washing utensils, glasses, cups, pots, pans, serving utensils, and mixing bowls in a two-compartment sink using detergent and bleach in the first compartment and bleach in the second compartment for sanitizing, with no clear rinse sink. She stated she was not keeping a log of the sink water temperatures or bleach sanitizer level. The Maintenance Director stated the old dish machine had gone out in September or October 2025, the new machine had been delivered in mid-November, and he and a Maintenance Director from another facility installed it but could not program it. He stated the machine tripped the breaker every time it was used and that an electrician was later scheduled to assess the breaker.
MDS assessments not encoded and transmitted
Penalty
Summary
The facility failed to ensure that a Quarterly MDS assessment for one resident and a Significant Change MDS assessment for another resident were encoded, accurate, complete, and electronically transmitted to the CMS system. Record review showed the Quarterly assessment for one resident was marked Export Ready but was never transmitted to CMS, and the Significant Change assessment for another resident was also marked Export Ready but was never transmitted to CMS. The report states these assessments were not completed and transmitted as required. One resident was an older female admitted and readmitted with diagnoses including type 2 diabetes, gout, unspecified dementia, hypertension, and a left leg amputation. Her record showed a Quarterly assessment dated [DATE], and a social work progress note indicated a meeting was held to complete the Quarterly assessment, with a BIMS score of 12 and continued monitoring as part of the plan of care. Another resident was an older female admitted and readmitted with diagnoses including COPD, unspecified dementia, and hypertension. Her record showed a Significant Change assessment dated [DATE] that remained Export Ready and was never transmitted to CMS. During interview, the VPCO stated the nurse now completing MDS assessments was the VPCR and that the new management company had been working through the assessments since taking over on 11/19/2025. She stated access to the SIMPLE website had been difficult because of the outgoing administrator and owner, and that the VPCR was having to log into both systems to get assessments up to date and transmit them to CMS. The ADMN acknowledged that the two MDS assessments should have been submitted long before the day of the interview. The facility policy stated assessments are to be transmitted to the designated CMS system within 14 days of completion, and the CMS RAI Manual excerpt stated encoding for Quarterly and Significant Change assessments must occur within 7 days after the MDS completion date.
Inaccurate MDS Coding for Insulin and Antiplatelet Therapy
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ health status for two residents whose assessments were reviewed. One resident had an order for NovoLIN R FlexPen ReliOn insulin to be administered one time weekly on Monday per sliding scale for type 2 diabetes mellitus, but the quarterly MDS dated 9/01/2025 documented that the resident received insulin injections daily. The resident’s August 2025 MAR documented FSBS levels every Monday and no sliding scale Novolin insulin administration. Another resident was admitted with atrial fibrillation and had an order for Clopidogrel 75 mg by mouth daily for atrial fibrillation, but the quarterly MDS dated 6/04/2025 documented that the resident received an anticoagulant medication. During interview, the VPCR reviewed both residents’ orders and MDS assessments and stated the insulin was inaccurately documented as daily and the Clopidogrel was inaccurately coded as an anticoagulant. The facility policy stated that assessments must accurately reflect the resident’s status and be completed by qualified staff using the RAI process.
Medication Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that residents were free from a medication error rate of 5% or greater, with an observed rate of 7.69%. This deficiency involved two residents who were administered insulin without the proper priming of the insulin pen. Specifically, LVN A and LVN B did not prime the Fiasp flex touch pen before administering insulin to two residents, which could result in the residents not receiving the full dose of insulin as ordered. This oversight was observed during medication administration and was confirmed through interviews with the involved LVNs and the Director of Nursing (DON). The residents involved were both diagnosed with Type 2 Diabetes Mellitus and were receiving insulin as part of their treatment plan. Both residents were cognitively intact, as indicated by their BIMS scores. The facility's policy on insulin injection and medication administration was not followed, as it requires the expulsion of air from the syringe before administration. The DON and LVNs were unaware of the need to prime the insulin pens, which contributed to the medication errors observed.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured and stored according to accepted professional principles, as observed with the West Hall Medication Cart and Treatment Cart. On one occasion, a treatment cart was left open and unattended in a hallway corner near a bathroom, with a resident within six feet of the unsecured cart. The cart contained medicated dressings, prescription ointments, and creams. An interview with LVN B confirmed that both LVNs had keys to the treatment cart and were responsible for ensuring it was secure. LVN B acknowledged that the cart should be locked if not in use or within the nurse's sight, as failure to do so could allow residents access to medications and treatment dressings. Another observation revealed an unlocked and unattended medication cart in the middle of a hallway, while the nurse was in a resident's room and not in line of sight of the cart. This cart contained over-the-counter and prescription medications, with the narcotic drawer secured by one lock. LVN C stated that the medication cart should be locked at all times to prevent resident access to potentially harmful medications. Interviews with the DON and ADM confirmed the expectation that medication and treatment carts should always be locked when not in use, as unsecured carts could lead to drug diversion or residents accessing medications not prescribed to them. The facility's policy on medication administration also emphasized the importance of locking the medication cart before entering a resident's room and never leaving it open and unattended.
Deficiency in Kitchen Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain food storage and preparation areas in accordance with professional standards for food service safety. During an initial tour of the kitchen, surveyors observed that refrigerator #1 had spilled dry milk on the bottom and underneath the shelves, with dust and food crumbs present in the corners and against the wall. The kitchen floor was also found to be dirty, with dirt, food crumbs, and trash underneath the shelves and along the walls. A follow-up observation confirmed that these conditions remained unchanged, despite a cleaning schedule being posted and initialed by the assigned staff as completed. Interviews with the Dietary Manager revealed that the refrigerators were supposed to be cleaned every Saturday by the evening cook, but this task was not completed as expected. The Dietary Manager, who was new to the job, stated that she was responsible for ensuring daily cleaning was done by checking the cleaning schedule for employee initials. However, a review of the dietary cleaning schedule showed several missing initials, indicating incomplete cleaning tasks. The Administrator expressed that it was his expectation for the kitchen to be cleaned daily and that any spills should be cleaned immediately to prevent infection and pests. The facility's policy on cleaning and disinfection, as well as the FDA Food Code, emphasized the importance of keeping nonfood-contact surfaces free of dust, dirt, and food residue.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN C during incontinence care for a resident. The resident, an elderly female with diagnoses including unspecified dementia, urinary tract infection, obesity, and depression, required assistance with most activities of daily living and was frequently incontinent. During an observation, LVN C did not perform hand hygiene or change gloves after they became soiled with urine and fecal matter while providing perineal care. Instead, LVN C continued to handle the resident's clean brief with the contaminated gloves. In an interview, LVN C acknowledged that her gloves were dirty and admitted that mixing clean with dirty items constituted cross-contamination, which could lead to infections. The Director of Nursing (DON) confirmed that staff were expected to follow proper infection control techniques, including hand hygiene and glove changes, to prevent infections such as urinary tract infections. The facility's Perineal Care in Nursing Procedure Manual also outlined the necessity of removing gloves, washing hands, and applying clean gloves during care, which was not adhered to in this instance.
Failure to Document Wound Care Properly
Penalty
Summary
The facility failed to ensure that wound care for a resident was performed in accordance with professional standards and the comprehensive person-centered care plan. Specifically, the nurses did not initial and date the wound dressings after performing wound care on a resident with a diabetic foot ulcer. This oversight was observed during an interview and observation where a Licensed Vocational Nurse (LVN) admitted to forgetting to date and initial the dressing after performing wound care the previous day. The resident, who has a history of Type 1 and Type 2 Diabetes, anemia, protein-calorie malnutrition, hyperlipidemia, hypokalemia, and cerebrovascular disease, confirmed receiving daily wound care without experiencing pain. The Director of Nursing (DON) stated that the expectation was for staff to date and initial wound dressings to verify that wound care was performed. The facility's Dressing Change Procedure also required documentation of the date, time, and initials on a piece of tape placed on the dressing. The failure to date and initial the wound dressing could lead to uncertainty about whether wound care was performed as ordered, especially if different nurses were working or if the nurse was not present the following day. This deficiency was identified for one of the two residents reviewed for quality of care.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Graham Oaks Care Center | 21.9 mi | ★★★★★ | 4 | 2 |
| Avir At Graham | 22.6 mi | ★★★★★ | 15 | 0 |
| Seymour Rehabilitation And Healthcare | 32.9 mi | ★★★★★ | 1 | 0 |
| Advanced Rehabilitation And Healthcare Of Wichita | 36 mi | ★★★★★ | 0 | 0 |
| University Park Nursing And Rehabilitation | 36.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.