Mount Olive Center

Inspectors wroteBased on record review, and resident, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of $300.00 after Resident #1 mistakenly transferred funds to Nurse Aide #1 on a money transfer application. This was for 1 of 3 residents reviewed for misappropriation of property (Resident #1).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to implement the abuse policy and procedures when the Administrator was not immediately notified of an allegation of misappropriation of funds resulting in delayed protection, reporting, and investigation for 1 of 3 residents reviewed for misappropriation of property (Resident #1).

Inspectors wroteBased on record review, and staff, Pharmacy Consultant, Medical Director, and Corporate Medical Director interviews, the facility did not ensure a resident was free of a significant medication error when Resident #1 received 60 milligrams (mg) of oxycodone (a short-acting opioid which is a class of drug used to reduce moderate to severe pain). Oxycodone 60 mg was not prescribed to Resident #1. On 11/28/25 Resident #1 was given oxycodone 60mg medication prescribed to another resident. This deficient practice affected 1 of 5 residents reviewed for significant medication error.

Inspectors wroteBased on record review and staff interviews, the facility did not maintain accurate records related to documentation of medication administration for 1 of 7 residents reviewed for accurate medical records (Resident #2).

Inspectors wroteBased on observations, record review, and resident, staff, Nurse Practitioner, (NP) Psychiatric NP and Medical Director interviews, the facility failed to assess a resident for self-administration of her enteral feedings (a method of delivering nutrition directly into the gastrointestinal tract, typically through a feeding tube, for individuals who cannot consume food orally) and to put effective interventions in place after Resident #13 was repeatedly observed by staff putting unidentified liquids in her gastronomy tube (g-tube [provides nutrition via a liquid formula delivered through a flexible tube that is surgically placed through the abdomen into the stomach]); rummaging through the trash for food /liquids; chewing and spitting out food items into the trash can; obtaining food as a prize for bingo; [...]

Inspectors wroteBased on record reviews and interviews with staff and the facility Consultant Pharmacist, the facility failed to provide ongoing Abnormal Involuntary Movement assessments to assess for potential adverse medication reactions for 2 of 3 residents (Residents #75 and #1) reviewed for receiving antipsychotic medications.

Inspectors wroteBased on record review, observations, staff interviews and Nurse Practitioner interview, the facility failed to administer supplemental oxygen as prescribed by the physician and failed to post cautionary signage indicating the use of oxygen for 3 of 9 residents reviewed for respiratory services (Resident #39, #91 and #49). 4. Resident #49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #49 was cognitively intact and was coded as receiving oxygen therapy. Physician orders dated 8/25/2025 included an order for oxygen at three liters per minute via nasal cannula every shift. Resident #49's care plan last updated on 8/26/2025 documented Resident #49 was at risk for respiratory complications and was receiving oxygen at 3 liters per min. [...]

Inspectors wroteBased on record review and interviews with staff, Consultant Pharmacist, and the Nurse Practitioner, the facility failed to address irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews (Residents #75, #113, #1, and #2) and to maintain documentation of the monthly drug regimen reviews within the facility and readily available for review (Resident #75). This deficient practice affected 4 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff, Pharmacy Consultant #1 and Nurse Practitioner and Cardiologist interviews, the facility failed to prevent a significant medication error when a resident was administered blood pressure medication with a blood pressure recorded below the parameters ordered by the physician for 1 of 6 residents whose medication regimens were reviewed (Resident #113).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to secure medications in an unlocked medication cart for 1 of 4 medications carts (medication cart #1) and to discard an unlabeled open vial of insulin from a refrigerator in a medication room (Nursing Station #2 medication room) and secure the locked refrigerated controlled medication black box to a permanent structure in 2 of the 3 medication rooms (Nursing Station #1 medication room and Nursing Station #3 medication room) reviewed for medication storage.

Inspectors wroteBased on record review, observation, and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen reviewed (Resident #39, and Resident #91) and medications (Resident #113) for 3 of 15 residents whose medical records were reviewed.1. Resident #113 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and heart failure. Physician's orders dated 7/25/2025 included Coreg 12.5 milligrams (mg) twice a day for blood pressure; hold for systolic less than 150 millimeters of mercury (mmHg). A review of Resident #113's July and August 2025 Medication Administration Record recorded Nurse #8 administered Coreg 12.5 mg with a blood pressure recording less than 150 mmHg: [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to administer enteral feeding formula at the correct rate as ordered by the physician for 1 of 1 resident (Resident #13) reviewed for enteral feedings (Resident #13).

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to provide written notice of transfer/discharge to residents and to the Ombudsman for residents who were transferred from the facility to the hospital for 2 of 5 residents reviewed for hospitalization (Resident #1 and Resident #10).

Inspectors wroteBased on record review, and staff interviews, the facility failed to post accurate daily nurse staffing information for 3 of 6 days reviewed (9/12/25, 9/13/25, 9/14/25).

Inspectors wroteBased on record review, and resident, staff, Nurse Practitioner (NP), surgical specialist's staff and Medical Director interviews, the facility failed to administer the bowel preparation (the process of cleaning out the intestines) on two separate occasions. The first was for a scheduled colonoscopy (an exam used to look for changes in the large intestine) on 12/17/24 and the second was for a limited sigmoid colon (part of the large intestine that is close to the rectum) resection (the process of cutting out tissue or part of an organ) for a suspicious colon polyp (small growths on the lining of the large intestine) scheduled on 2/24/25. Review of the hospital Discharge summary dated [DATE] revealed Resident #4 was placed under general anesthesia and the abdominal incisions had been made when the surgeon observed the colon was full of stool and aborted the surgery. [...]

Inspectors wroteBased on record review, and resident and staff interviews the facility failed to ensure cognitively intact residents who were assessed as unsafe smokers were supervised while smoking and did not have smoking materials in their possession for 2 out of 4 residents reviewed for smoking (Residents #1 and #2).

Inspectors wroteBased on record review, and interviews with staff, medical physician, responsible party, nurse practitioner and paramedic, the facility failed to ensure staff notified the physician when a resident (Resident # 13) was observed by nurse aides to be zonked, talking out of his head, not eating any of his supper meal and complaining of being tired in conjunction with a new rash observed on multiple areas of his body by multiple staff members. Additionally, one staff member referenced the rash as a death rash and thought the physician had already been notified. The resident was transferred to the hospital by emergency services when staff called 911 the following day. The resident was identified to be in septic shock and expired while hospitalized . [...]

Inspectors wroteBased on record review, and interviews with staff, physician, and paramedic, the facility failed to ensure staff recognized the need for communication amongst themselves and with the physician to ensure a resident received medical services to address an emergency situation (Resident # 13). Resident # 13 reportedly had a death rash in conjunction with nurse aides' observations of him being zonked, talking out of his head, not eating any of his supper meal and complaining of being tired. The morning following these observations, which were noted by staff members on the previous evening and night shift, the resident was found by the morning shift staff nurses to be without a detectable radial pulse, without a detectable oxygen level, mottled skin (discolored patches of skin which can result from a lack of blood flow to the skin), and not responding to a sternal rub. [...]

Inspectors wroteBased on record review, and interviews with staff, Responsible Party, Nurse Practitioner and Medical Director the facility failed to 1) ensure staff were providing transfer assistance as care planned for a resident (Resident # 1) identified as at risk for injuries due to osteoporosis and 2) ensure mats were at the bedside to prevent injuries for a resident with a history of falls (Resident # 2). Resident # 2 sustained a large hematoma and fractured nose when she was found on the floor without a fall mat in place. This was for two of three sampled residents reviewed for accidents (Resident #1 and Resident #2).

Inspectors wroteBased on observation, and interviews with staff and Responsible Party the facility failed to follow up with an audiologist's recommendation when one of Resident # 5's hearing aids was lost and the other broken. This was for one of one sampled resident with hearing loss (Resident #5).

Inspectors wroteBased on record review, and interviews with staff the facility failed to provide sufficient staff to ensure a resident (Resident # 2) received an assessment prior to being moved following a fall with a head injury. This was for one of two residents identified not to receive medical services on the night shift which began on 9/3/24 at 11:00 PM.

Inspectors wrote2. Resident # 13 was admitted to the facility on [DATE]. On 8/30/24 at 5:44 PM Nurse # 4 documented Resident # 13 was complaining of his catheter feeling weird during the shift of 7AM to 7PM. He had been found to have some swelling in his groin which he reported had happened before. The catheter was deflated and removed, and the resident refused to have the catheter reinserted. He was voiding in a urinal. The physician had been contacted and reported to monitor the resident and send him out if he had pain or problems voiding. A review of the record revealed the catheter was never reinserted prior to the resident's discharge on [DATE]. The order remained in the resident's electronic medical record for him to have a catheter. Nurse # 5 had cared for Residednt # 13 on 9/3/24 from 7:00 AM to 7:00 PM. Nurse # 5 was interviewed on 9/26/24 at 1:40 M and again on 9/30/24 at 12:15 PM. [...]

Inspectors wrote2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included hypertension, spinal stenosis (the space inside the backbone is too small) and lymphedema (a chronic condition that causes localized swelling in the body due to a buildup of lymph fluid). Resident #43's most recent Minimum Data Set assessment dated [DATE], a quarterly assessment revealed he was cognitively intact. He was assessed as requiring substantial assistance for bed mobility and transfers. During an observation and interview on 6/24/24 at 12:05 PM a half-full open urinal was observed on Resident #43's right bed rail. A urine smell was present. Resident #43 stated his urinal was not emptied as often as he would like. He reported that he feels the urinal has the potential to attract pests and he can smell the urine. Resident #43 stated he uses the urinal without assistance. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to allow cooking pans and dome lids to completely dry prior to assemblage and stacking for two of two observations. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by observations of fly activity in the kitchen, in resident rooms (Resident #113, Resident #24, and Resident #102), and on the 100 and 300 halls. Additionally, the facility failed to utilize insect light traps (installed to trap flies) and implement recommendations made by the pest control service provider to prevent reoccurring pest activity in the kitchen area. This deficient practice had the potential to affect residents in the facility.

Inspectors wrote2. Resident #125 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #125 was cognitively intact. The care plan dated 2/20/24 revealed Resident #125 was admitted for skilled short-term stay and Resident #125 would have an ongoing discharge plan that provided for a safe and effective discharge. Review of the care plan meeting sign in sheet dated 6/07/24 revealed the Social Service Director and the MDS Nurse #1 conducted Resident #125's care plan meeting. The sign in sheet was noted by the Social Service Director that Resident #125 was not able to come due to care, and Resident #125's Power of Attorney (POA) was called, and message was left. The sign in sheet further reported Resident #125 was communicated later of care plan. [...]

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discontinue the use of a wander guard for a resident based on a physician's order and the elopement assessment on 1/30/2024. The resident was observed with a wander guard on the left ankle with no physician's order for the use of a wander guard for elopement prevention and no documentation of the monitoring of the use of the wander guard for 1 of 7 residents reviewed for accidents (Resident #120).

Inspectors wroteBased on record review and Nurse Pracitioner and staff interviews, the facility failed to provide speech therapy services as ordered for 1 of 1 resident reviewed for therapy services (Resident #287).

Inspectors wroteBased on resident and staff interviews the facility failed to provide residents the right to receive mail when delivered on Saturday. This had the potential to affect 127 of 127 residents residing in the facility.

Inspectors wroteBased on staff interviews and record review, the facility failed to post nurse staffing information at the beginning of each shift for 2 of 4 days during the survey and failed to post nurse staffing information for 47 of 57 days reviewed from 5/1/24 through 6/26/24.