Inspection Reports for
Mount Olivet Careview Home

The complaint investigation found that the facility did not properly document the reason for PRN narcotic medication administration or non-pharmacological interventions tried prior to administration. Interviews with nursing staff and the director of nursing confirmed that proper documentation and attempts at non-pharmacological interventions are required but were not consistently performed.

The facility failed to document the indication for PRN narcotic medication administration and did not ensure non-pharmacological interventions were attempted or offered prior to administration for two residents reviewed. Documentation lacked pain assessments, symptoms, and non-pharmacological interventions before PRN morphine was given.

The facility was found deficient in multiple areas including failure to honor residents' dignity related to facial hair grooming, incomplete assessment for medication self-administration, failure to honor food preferences, incomplete care planning for urinary tract infections, inadequate pressure ulcer prevention and care, failure to implement fall prevention interventions, unqualified feeding assistance, and improper infection control practices related to COVID-19 and enhanced barrier precautions.

The complaint investigation substantiated that the facility failed to report and investigate sexual abuse incidents involving resident R1 who was sexually abused by resident R2 on 7/6/24 and 7/10/24. Immediate jeopardy was identified on 7/15/24 and removed on 7/16/24 after corrective actions.

The facility failed to report and investigate sexual abuse incidents involving one resident (R1) who was sexually abused by another resident (R2) on multiple occasions. Immediate jeopardy was identified but later removed after corrective actions including 1:1 supervision and staff education were implemented.

The investigation was complaint-driven based on family member reports and video evidence showing residents not receiving timely meals or assistance. Staffing shortages were cited as a contributing factor. The complaint was substantiated with findings of missed care and inadequate care plan updates.

The facility failed to provide care in accordance with residents' written plans for 4 of 5 residents reviewed, including failure to provide meals and assistance with eating, hygiene, and transfers. Staffing shortages contributed to missed care and inadequate supervision.

The facility failed to ensure comprehensive and updated care plans for two residents. Resident R2's care plan was not updated after a hospital readmission for a femur fracture, and Resident R3's care plan lacked documentation of multiple bruises and contributing medical diagnoses.

The complaint investigation was substantiated as the facility failed to maintain wheelchair safety, resulting in a resident fall without injury. The resident could not verbally express herself or call for help during the incident.

The facility failed to implement scheduled maintenance safety checks on wheelchairs, resulting in a resident falling when the back of her wheelchair became unattached. Interviews revealed no formal safety inspection system, and the facility only cleaned wheelchairs monthly without performing safety checks.

The complaint investigation found that the facility did not notify the resident's family of significant changes in condition, including weight loss and diminished appetite, in a timely manner. Family members reported being unaware of the resident's decline until shortly before hospitalization. The complaint was substantiated.

The facility failed to notify the resident's family of significant weight loss and changes in condition in a timely manner. Interviews and document reviews confirmed that the resident experienced a significant decline and weight loss, but family notification was delayed until after the resident was hospitalized and subsequently expired.

The investigation was complaint-driven, focusing on the timeliness of medical assessment and X-ray after a resident fall. The complaint was substantiated with findings of delayed X-ray and assessment due to resident behavior and staffing limitations.

The facility failed to ensure that one resident (R1) received an X-ray in a timely manner after a fall resulting in a fractured hip. Delays were due to resident combativeness and unavailability of X-ray technicians, with the X-ray performed the morning after the fall.

The facility failed to ensure a valid Provider Orders for Life-Sustaining Treatment (POLST) was completed and signed for one resident. Additionally, the facility failed to maintain safe refrigerator temperatures below 41 degrees Fahrenheit in multiple dining room refrigerators, potentially affecting 14 residents.