Olivia Restorative Care Center

Inspectors wroteBased on interview and document review, the facility failed to ensure medications used to manage pain were provided timely after being ordered, despite a supply of the medication being available in the onsite emergency kit (E-Kit), for 2 of 3 residents (R2, R3) reviewed.

Inspectors wroteBased on interview and document review the facility failed to report an allegation of abuse timely to law enforcement and the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse.

Inspectors wroteBased on interview, and document review, the facility failed to correctly transcribe medication orders according to physician instructions, for 2 of 4 (R10 and R11) residents reviewed for transcription of orders. This error resulted in R10 missing four doses of her long- acting insulin that led to her re hospitalization to intensive care units (ICU) due to diabetic ketoacidosis (DKA), a serious complication of diabetes.

Inspectors wroteBased on interview and document review, the facility failed to have licensed nursing coverage on staff for 24 hours a day, based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed - Quarter 2, 2025, (January 1 to March 31st), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 39 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day, 7 days per week, for 6 of 90 days reviewed. This had the potential to affect all 39 residents living in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure infection control practices were maintained to ensure dietary staff were wearing a hair net and/or beard nets while in 1 of 1 kitchen and during meal services. The facility also failed to ensure 1 of 2 dining room refrigerators remained clean, and food was dated within the refrigerator to ensure it was not used beyond expiration. Additionally, the facility failed to ensure all Chlorine test strips for monitoring the dishwasher chemical level were not expired.

Inspectors wroteBased on interview and document review, the facility failed to implement 1 of 1 facility assessment and ensure the required nursing staff were scheduled and working to provide care and services to residents.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate staffing data based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed - Quarter 2, 2025, (January 1 to March 31st), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 39 residents living in the facility.

Inspectors wroteBased on observation and interview the facility failed to disinfect 1of 2 glucometers (capillary blood glucose sampling device) after use to prevent transmission of blood borne diseases. Additionally, the facility failed to complete accurate staff illness surveillance for 2 of 2 staff.

Inspectors wroteBased on observation, interview, and document review, the facility failed to update code status for 1 of 16 resident (R40) who requested to have his code status changed.

Inspectors wroteBased 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. The administrator, director of nursing (DON), and nurse consultant were notified of the immediate jeopardy on 5/29/25 at 9:30 a.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to have a system to ensure residents who were cognitively intact, and not an elopement risk could freely enter and exit the facility for 1 of 1 residents (R5) reviewed for resident rights.

Inspectors wroteBased on interview and document review, the facility failed to ensure contracted resident care staff were competently trained on facility resident procedures, as well as provided access to electronic medical records (EMR) to implement person-centered resident care needs, interventions related to resident care to ensure safety and reduce the risk of complication (i.e. elopement). This had the potential to affect all 46 residents currently residing in the facility.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and document review, the facility failed to implement their Abuse, Neglect, and Exploitation and Elopements and Wandering Resident policy for 1 of 3 (R1) residents reviewed for elopement.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an elopement from the facility was recognized and reported to the State Agency (SA) for 1 of 1 resident (R1) reviewed for elopement.

Inspectors wroteBased 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. This resulted in a system wide failure in infection control procedures to prevent the spread of illness within the facility resulting in an immediate jeopardy (IJ) which placed all residents at a high likelihood of serious illness and/or death by contracting a communicable respiratory disease. [...]

Inspectors wroteBased 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. The Administrator, director of nursing (DON) were notified of the IJ on 4/8/25 at 6:32p.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to complete an assessment including, vital signs and general condition, when a change in condition was reported to a nurse for 1 of 3 (R1) residents reviewed for quality of care. This resulted in harm for R1 who continued to decline and later that day required emergency medical care and passed away.

Inspectors wroteBased on observation and interview the facility failed to employ a full-time director of nursing (DON). This had the opportunity to affect all 36 residents.

Inspectors wroteBased on interview and document review, the facility failed to provide training to individuals providing services under a contractual agreement, consistent with their expected roles. This had the opportunity to affect all 36 residents of the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 carpeted center hall transition space to the center hall wood floor, 1 of 1 center hall wood floor transition space to the north carpeted hall, and 1 of 1 north carpeted hall transition space to resident (R14)'s tile floor was maintained to promote a safe, sanitary, and homelike environment. This had the potential to affect 11 residents that ate in the north dining room and/or lived on the north hall.

Inspectors wroteBased on observation and interview the facility failed to ensure residents were assisted with their meal in a dignified manner for 3 of 6 residents (R1, R11, R23) who were dependent on staff to assist them with meal intake.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a discharge record for 1 of 12 residents (R37) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that 1 of 1 resident (R29) had hearing aids appropriately replaced when staff failed to remove her hearing aid during bathing, causing it to be damaged by water, and assist R29 with replacement due to staff negligence.

Inspectors wroteBased on observation, interview, and document review, the facility failed to obtain and administer ordered pain medication patched (lidocaine) medication for 1 of 6 residents (R189).

Inspectors wroteBased on interview and document review, the facility failed to act upon pharmacy recommendations to modify administration times and limit potential interaction and/or side effects for medication administered to 1 of 3 residents (R34).

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 residents (R24 and R33) were offered pneumococcal PCV-15 or PCV-20 vaccination or declination form, per Centers for Disease Control (CDC) recommendations, reviewed for vaccinations.

Inspectors wroteBased on observation, interview and document review the facility failed to assess and identify which mechanical lift and corresponding slings were to be used based off each resident's height and weight, for 10 of 10 residents (R2, R4, R5, R6, R7, R8, R9, R10, R11 and R12) who utilized a total mechanical lift for transfers. This resulted in a pattern of no actual harm but potential for more than minimal harm that is not immediate jeopardy.

Inspectors wroteBased on observations, interview and document review, the facility failed to ensure 1 staff member hired as a registered nurse (RN) was not employed by the facility with a disciplinary action in effect against his professional license by the Minnesota (MN) Board of Nursing. In addition the staff member hired as a RN did not hold a RN license, the staff's licensed practical nurse (LPN) license was suspended. This had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician ordered wound treatments and failed to ensure appropriate infection control practices during wound care including hand hygiene to prevent or mitigate the risk of wound deterioration and/or infection for 2 of 2 residents (R2, R3) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to have a comprehensive IC surveillance program that included employee illness and criteria to return to work. There facility also failed to ensure existing policies were reviewed annually to ensure they were updated and complete. This had the ability to affect all 41 residents.

Inspectors wroteBased of interview and document review, the facility failed to perform antibiotic stewardship to include antibiotic use protocols and a system to monitor antibiotic usage and determine if the prescribed antibiotics resolved the identified infectious process for 15 of 41 sampled residents (R2, R6, R9, R10, R12, R24, R26, R27, R31, R34, R35, R37, R244, R245, and R246) identified in the facility's infection control surveillance. This had the potential to affect all 41 residents who were or may receive antibiotic therapy in the future.

Inspectors wroteBased on observation, interview, and document review the facility failed to verify and document lorazepam 1 milliliter (ml) vials located in the facilities emergency kit kept in the medication room refrigerator.

Inspectors wroteBased on interview and document review, the facility failed to ensure 5 of 5 residents (R2, R6, R17, R33 and R144) were offered and/or administer vaccination for pneumonia upon admission or when eligible. Furthermore, the facility failed to update their policy and educate staff to ensure the facility offered and/or provided any initial or updated pneumococcal vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. This had the ability to affect all 41 residents.

Inspectors wroteBased on interview and document review, the facility failed to honor 1 of 1 (R18) residents' choice for male aid to assist with bathing.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess 1 of 1 resident (R241) following a fall resulting in delayed evaluation and treatment by a physician.

Inspectors wroteBased on observation, interview and document review, the facility to develop an individualized care plan to address the emotional and psychosocial needs of 1 of 1 resident (R17) with a history of PTSD and trauma.

Inspectors wroteBased on observation, interview and document review the facility failed to follow nursing standards of practice for 1 of 25 medication administrationobservations. The facility also failed to follow the 5 rights of medication administration to ensure staff dispensed the correct dose of diazepam 2.5 milligrams, for 1 of 1 resident (R142). The facility also failed to check the medication administration record against the medication label prior to giving medication for 4 of 17 residents (R17, R19, R20, and R142). The facility also failed to ensure 1of 1 resident (R31) had medication available for administration.

Inspectors wroteBased on interview and document review the facility failed to monitor for side effects for 1 of 5 residents (R25) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the State Agency (SA) were notified within 2 hours of staff witnessing allegations of resident-to-resident sexual abuse for 1 of 1 residents (R1) when R2 inappropriately placed his hands inside R1's shirt.