Olivia Restorative Care Center

In the surveyor’s words

From the most serious findings on record at Olivia Restorative Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Apr 9, 2025

  Based on observation, interview, and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Respiratory Syncytial Virus (RSV- an infection of the respiratory tract). As a result, the facility developed an outbreak where 8 residents (R10, R13, R14, R11, R12, R17, R6, and R16) tested positive for RSV and 3 residents were suspected to have RSV (R15, R7, R18); 2 residents (R10 and R12) were seen in the emergency department (ED) and 3 residents (R11, R13, and R14) were hospitalized at a higher level of care. […]

• Immediate jeopardy, isolatedF689May 30, 2025

  Based on observation, interview, and document review, the facility failed to provide assessed supervision needs for 2 of 3 residents (R1, R4) who were at risk for elopement. R1 was able to leave the facility undetected for one hour despite having a wander guard on, which resulted in an immediate jeopardy (IJ). The IJ began on 5/21/25, when R1, while wearing a wander guard bracelet, successfully eloped from the building without the alarm sounding. R1 was allowed out of the locked front entrance by an unknown responsible party (had the pin code to the locked door), crossed a highway, and was found by community members approximately one mile from the facility an hour later, winded but unharmed. […]

• Immediate jeopardy, isolatedF689May 12, 2025

  Based on observation, interview, and document review, the facility failed to comprehensively assess supervision needs, develop individualized person-centered interventions to mitigate risks and hazards for 1 of 3 residents (R1) reviewed for elopement risk. This resulted in an immediate jeopardy (IJ) when R1 left the facilty without staff knowledge and was found 12 blocks away, unharmed by a community member. The immediate jeopardy began on 5/5/25 when R1 left the facility and was found by a community member several blocks away confused, and returned to the facility by local police. The IJ was identified on 5/8/25. The administrator, director of nursing (DON), director of operations, and director of clinical operations were notified of the immediate jeopardy on 5/8/25 at 5:10 p.m. […]

• Immediate jeopardy, isolatedF689Apr 9, 2025

  Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, revise the care plan and implement appropriate interventions to prevent and/or reduce the risk of falls with major injury for 2 of 3 residents (R20, R22) who had falls. This resulted in an immediate jeopardy for R20 who had a history of traumatic brain injuries and sustained a fall that resulted in a subdural hematoma and was hospitalized . The IJ began on 3/28/25 after R20 had a fall, the facility failed to assess and implement appropriate interventions to prevent/mitigate risk for falls which resulted in R20's fall on 4/4/25 in which R20 suffered an intercranial brain injury and hospitalization. […]

• Immediate jeopardy, isolatedF689Jun 30, 2022

  Based on interview, observation, and document review, the facility failed to provide adequate supervision despite being a known elopement risk, for 1 of 1 residents (R1) who left the facility, self-propelling in a wheelchair with the intent of returning to his home, over a mile away, with an air temperature at 90 degrees Fahrenheit (F). A stranger subsequently picked up R1 a few blocks away from the facility and brought him to R1's home in the community. This resulted in an immediate jeopardy (IJ) for R1 when, after he was returned to the facility on [DATE], the facility failed to place interventions that would prevent reoccurrence, placing R1 at risk for serious harm, injury, or death if he should elope again. […]