Mount Olivet Home

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 30, 2025

  Based on observation, interview and record review, the facility to ensure interventions were implemented for 2 of 2 residents (R83, R5) and a root cause analysis was completed for 1 of 2 residents (R5) after a fall. This lead to actual harm for both R83 and R5 when R83 fell and sustained a right hip fracture that required hospitalization and surgery and when R5 fell and sustained a right clavicle fracture that required hospitalization . In addition, the facility failed ensure an elopement risk assessment was completed for 1 of 1 residents (R79) who had attempted to elope and failed to provide monitoring for 1 of 1 residents (R47) who had complaints of coughing during meals. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2024

  Based 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. Findings include: Ecolab EC-66HH specifications sheet dated 2012, indicated the dishwasher operating temperatures for high temp wash was 160 degrees F. The operating temperature for sanitizing rinse was 180 degrees F. A facility document titled Culinary Services Dish Washer Temperature Log dated 6/2024, indicated logged final rinse temperatures hit 180 degrees F one time from 6/1/24-6/26/24. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based 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.Findings include:During initial tour with director of culinary services (DCS) on 5/11/26 at 11:10 a.m., a series of 4 white-colored plastic bins were observed in the food preparation area. The wheeled bins were on the floor and were labeled for flour, white sugar, rice and powdered sugar. […]

• No harm, potential for more than minimal, patternF755Jun 27, 2024

  Based 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. […]