Helia Healthcare of Olney

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the planned menu was provided to residents. This has the potential to affect all 71 residents residing in the facility. The Findings Include: 1. On 5/19/26 the meal planned for lunch for the week 'at a glance' menu was chicken breast supreme, carrots, green beans and peach slump cake. On 5/19/2026 at 11:30 AM the meal provided to the residents was a chicken patty or beef patty, corn, green beans and cake with whipped topping. V4 (Culinary Assistant) was asked why the chicken breast supreme was not served as planned. V4 stated that someone forgot to get the chicken thighs out of the freezer the night before and she did not have enough time to get them thawed and cooked for lunch today. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to offer meal substitutions that were appealing and of similar nutritive value to residents. This has the potential to affect all 71 residents residing in the facility. The Findings Include: On 5/19/26 during the lunch meal service at 11:00 AM a chicken patty, green beans, carrots and peach cake was served to all residents. The planned menu for 5/19/26 was chicken supreme, carrots, peach slump cake, and green beans. V4 (Culinary Assistant) stated she did have a beef patty for those who do not want chicken but no alternative to the vegetable and the meal was not served with any type of bread. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that proper sanitation of dishes and cleanliness of equipment was maintained to prevent cross contamination. This failure has the potential to affect all 71 residents residing in the facility. The Findings Include:On 05/19/2026 at 9:55 AM during the initial kitchen walk through the following observations were made:Dirt and debris were observed under the floor mounted stainless-steel tables. The oven/stove had a layer of grease/dust build up on the top shelf over the stove, the back splash/sides/oven doors and oven top were full of old food splatters and dried spills. The dish machine had no sanitizer registering on the chlorine test strips. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that resident meals were delivered at appetizing/preferred temperatures for 5 of 5 (R8, R14, R19, R44 and R73) residents reviewed for cold food complaints in a sample of 49. The Findings Include:During the resident council meeting on 5/20/26 at 1:00 PM, R8, who was alert and oriented, stated the food is cold when it is delivered to her room. R8 stated she eats most meals in her room by choice but most of the time if she is hungry, she has to eat cold food. R14 , R19 and R44 who are alert and oriented to person place and time, stated they have complained about the food temperatures in the resident council meetings. On 5/21/26 at 9:00 AM, R8 stated by the time her breakfast tray was delivered this morning it had cold eggs and French Toast on it, so she did not eat very much of it. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receive food items in accordance with physician orders for safe swallowing/therapeutic diets for 18 of 18 residents (R4, R6, R13, R14, R16, R21, R22, R26, R27, R29, R34, R35, R45, R47, R52, R53, R64 and R65) reviewed for therapeutic diets in a sample of 49.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident equipment was maintained in a state of good repair for 1 (R58) of 18 residents reviewed for environment in the sample of 49.

Inspectors wroteBased on interview, observation and record review the facility failed to provide range of motion program per COTA (Certified Occupational Therapy Assistant) recommendations to a resident with limited range of motion to prevent further reduction of range of motion (ROM) for 1 (R40) of 18 residents reviewed for range of motion in the sample of 49. The Findings Include: R40's Face Sheet documents an admission date to the facility of 01/23/2025. The diagnoses listed include cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right side, speech and language deficits following cerebral infarction, chronic kidney disease, and insomnia. [...]

Inspectors wroteBased on interview and record review, the facility failed to safely transfer and reposition 1 of 5 residents (R1) reviewed for safe resident handling in the sample of 13. This failure resulted in R1sustaining a fractured left humerus on [DATE] when the staff failed to use a gait belt to reposition R1.

Inspectors wroteBased on interview and record review, the facility failed to promptly assess and treat a resident with severe pain for 1 of 10 Residents (R1) reviewed for pain in the sample of 13. This failure resulting in R1 experience severe pain for a period of approximately 4 hours after sustaining a fractured left humerus.

Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency medications and failed to correctly document medications not administered as ordered for 1 of 10 residents (R1) reviewed for pharmacy services in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 3 (R1) residents reviewed for abuse in the sample of 18. This past non-compliance occurred between [DATE] and [DATE]. Findings Include:R1's undated Resident Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia with mood disturbances, heart failure, anxiety disorder, Parkinsonism, and localized edema. R1's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status score of 07, indicating a moderate cognitive deficit. R1's Care Plan documents a Problem area with a start date of [DATE] of, Category: Behavioral Symptoms, Resident is alert and able to let his needs be known most of the time. He has dx (diagnoses) of depression and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication cart was locked and its keys were not accessible to 4 (R31, R42, R58 and R66) of 4 confused ambulatory residents reviewed for safe and secure storage of medications in the sample of 34. On 04/09/25 at 08:05 AM, V5 (Registered Nurse/RN) was observed passing medications on B Hall. V5 prepared medications for a resident and entered the residents room, leaving the medication cart unlocked and the cart keys on top of the cart, and out of V5's visual control. On 04/09/25 at 08:13 AM, V5 prepared medications for another resident and left the cart keys on top of the cart and out of V5's visual control. During these observations, there were residents or staff near the cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and implement gradual dose reductions (GDR's) as recommended by the pharmacist and/or document a rationale for contraindication for 1 (R13) of 5 residents reviewed for unnecessary psychotropic medications in the sample of 34. Findings Include: R13's Face Sheet documented R13 was admitted to the facility on [DATE] and included the following diagnoses: acute and chronic respiratory failure, undifferentiated schizophrenia, type 2 diabetes mellitus, convulsions, hepatic failure, depressive disorders, chronic obstructive pulmonary disease, essential hypertension, sleep apnea, heart failure, atrial flutter, generalized anxiety disorder, and gastro esophageal reflux disease. [...]

Inspectors wroteBased on interview, and record review the facility failed to monitor temperatures of coffee to prevent burns for 1 (R1) of 3 residents reviewed for accidents in the sample of 4.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure dishware was sanitized appropriately. This has the potential to affect all 66 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food portions as directed by the approved menu for 4 (R42, R45, R58, R168) of 12 residents reviewed for nutrition in a sample of 40.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 2 (R56, R58) of 12 residents reviewed for nutrition in a sample of 40.