Mount Olivet Home

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 1 of 1 commercial can opener was kept in a clean and sanitary manner and failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk of cross-contamination. These findings had the potential to affect all 80 residents, staff, and visitors who consumed food prepared from the main production kitchen.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide a dignified experience for 1 of 2 residents (R20) who was receiving medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal hygiene care (i.e., nail care, hair washing, showers) was provided for 1 of 1 resident (R36) reviewed for activities of daily living (ADLs) and who was dependent on staff for his care.

Inspectors wroteR5 R5's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), orthostatic hypotension, and a history of falls. It further indicated impairment on bilateral lower extremities (LE), independent with toileting and mobility, was occasionally incontinent of urine and always continent of bowel. Shortness of breath (SOB) when laying flat, had a fall within the last 2-6 months prior to admission/entry or reentry, and received an antidepressant and diuretic on a routine basis. R5's Care Area Assessment (CAA) triggered for falls from the MDS (11/27/25) for the following reasons: [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food items were labeled and dated, three of three kitchenettes were not properly cleaned per facility policy and cleaning log manual. This had the potential to affect all residents whom consumed beverages from the kitchenettes. During the initial observation of kitchenette on 2nd floor on 4/28/25 at 2:04 p.m., there was one filled frozen dixie cup no name or label in freezer, and one 20-ounce bottle of Gatorade one third opened no name or label in refrigerator. The ice/water machine had white flaky substance on back by dispenser. Folgers coffee machine had scant amount of brown tinged dried brown liquid on bottom of grate. [...]

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a comprehensive care plan to include identified trauma-related triggers and individualized trauma-informed care approaches for 2 of 2 residents (R14, R77) who had a history of trauma.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure wound care orders were followed and implemented for 1 of 3 residents (R27) reviewed for skin conditions.

Inspectors wroteBased on interview and document review, the facility failed to ensure identified triggers were documented in the comprehensive care plan and individualized trauma-informed approaches were utilized for 2 of 2 residents (R14, R77) who had a history of trauma.

Inspectors wroteBased on interview and document review, the facility failed to collaborate with hospice for the development, implementation, and revision of the coordinated plan of care for 1 of 1 residents (R34) reviewed for hospice services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper sanitization of dishware used for meal prep and resident service when the high temperature sanitizing dishwasher was not reaching adequate wash and rinse temperatures. This had the potential to impact all 92 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure insulin was to be administered to the correct resident and failed to ensure appropriate medication receiving procedures were followed for 1 of 3 residents (R18) observed for insulin administration. Additionally, the facility failed to provide pharmaceutical services to meet each resident's needs which included receiving the correct resident's medications and disposing of a discharged resident's medications. This had the potential to affect all who residents who received insulin residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure insulin pens were labeled in accordance with professional standards for 2 of 3 residents observed during insulin administration. Furthermore, the facility failed to ensure insulin pen-injectors were stored in a locked compartment. This had the potential to affect all 31 residents residing on the locked memory care unit.

Inspectors wroteBased on observation, interview, and document review, the facility failed to accommodate resident preference and assist in maintaining and/or achieving independent functioning for 3 of 3 residents (R16, R60, R61) reviewed who expressed a desire to open the windows in their rooms as they wished.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an electric lift chair was assessed for safe use for 1 of 1 residents (R11) reviewed for positioning. R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had cognitive impairment and diagnoses of osteoporosis (disease causing weak bones), spinal stenosis (narrowing of the spinal column) and dementia. Furthermore, R11's MDS indicated R11 required partial to moderate assist from sit to stand and used a walker for mobility. R11's physical device data assessment dated [DATE], indicated R11 was not assessed for safe use of an electric lift chair. R11's care plan dated 5/7/24, indicated R11 required staff assistance as needed for transfers. R11's care plan lacked indication R11 used an electric lift chair or required assistance with use. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement resident-specific non-pharmacological interventions to address pain according to the resident's goals and preferences for 1 of 1 residents (R15) reviewed for pain.

Inspectors wroteBased on interview and record review the facility failed to ensure nonpharmacological interventions were utilized before use of an as needed (PRN) antipsychotic medication and failed to ensure PRN antipsychotic medication was ordered for 14-day use for 1 of 1 residents (R9) reviewed for PRN antipsychotic medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure hand hygiene and glove change occurred between dirty and clean tasks and a shared glucometer (blood glucose meter) was disinfected between 3 of 3 residents (R53, R18, R28) observed during blood sugar checks.