Mount Olivet Careview Home

In the surveyor’s words

From the most serious findings on record at Mount Olivet Careview Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 16, 2024

  Based on interview and document review the facility failed to report, investigate, and initiate interventions for sexual abuse resulting in subsequent sexual abuse for 1 of 3 residents (R1). R1 was sexually abused by R2 on 7/6/24, and again on 7/10/24. The immediate jeopardy began on 7/6/24 when RN-A failed to report an allegation R2 had touched R1 between her legs over her clothing and was identified on 7/15/24. The director of nursing, assistant director of nursing, associate administrator, and nurse manager were notified of the immediate jeopardy at 4:45 p.m. on 7/15/24. […]

• Immediate jeopardy, isolatedF760Apr 30, 2021

  Based on interview and document review, the facility failed to ensure hospital orders were transcribed correctly to ensure the ongoing therapeutic dosing of anticoagulant medication to prevent reoccurrence of blood clots in 1 of 1 resident (R1) reviewed for significant medication error. These findings constituted an immediate jeopardy (IJ) situation for R1. However, the facility had taken appropriate action(s) to correct the identified non-compliance and, as a result, the findings are being issued as past non-compliance. […]

• No harm, potential for more than minimal, patternF880Jan 16, 2025

  Based on observation, interview, and document review, the facility failed to use proper infection control practices to prevent and/or mitigate the risk of a potential infection outbreak for 3 of 12 residents (R42, R57, R118) observed for respiratory precautions, and 1 of 4 residents (R138) observed for enhanced barrier precautions. Findings include: PPE FOR COVID-19 R42's quarterly Minimum Data Set (MDS) 10/23/24, indicated R42 had severe cognitive impairment, was dependent on staff for most activities of daily living (ADL's) and required supervision or touching assistance with eating. R42's physician order dated 1/7/25, indicated R42 had an active COVID-19 infection in the contagious stage and required transmission-based precautions for ten days. […]

• No harm, potential for more than minimal, patternF677Jun 4, 2024

  Based on observation, interview and document review, the facility failed to provide services in accordance with the resident's written plan of care for 4 of 5 residents (R1, R3, R4, R5) who were dependent upon care of others to perform activities of daily living (ADLs). In addition, the facility failed to develop and implement a comprehensive care plan to reflect the resident's current needs for 2 of 2 residents (R3, R4) reviewed for activities of daily living. Findings include: R1's quarterly Minimum Data Set (MDS) dated ,d+[DATE]//24, indicated R1 had severe cognitive impairment, required moderate assistance with eating and was dependent upon staff for hygiene and transfers. R1's diagnoses list printed 6/4/24, indicated dementia and osteoarthritis. […]

• No harm, potential for more than minimal, patternF689Jun 26, 2023

  Based on interview, and record review the facility failed to implement interventions for assistive devices for 4 of 4 residents (R1, R2, R3, and R4) assessed for accidents. R1 was found hanging from her IRIS wheelchair when the back of the wheelchair became unattached. The facility did not have a system for maintence safety checks on their wheelchairs to prevent potential harm. Findings include: The Quickie IRIS owner's manual undated indicated the user or caregiver should perform these weekly and monthly checks to maintain the safety of their chair. Weekly: Tire inflation level, wheel locks, rollers, tilt cables and plunger and rocker arm. Every three months: Visually check for loose hardware, quick release axles, wheels, tires and spokes, casters, anti-tip tubes. […]