Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Olivia Restorative Care Center during CMS and state inspections, most recent first.
A resident with a history of traumatic sexual abuse and intact cognition reported inappropriate sexual contact by a nursing assistant during personal care. Despite multiple staff and leadership being made aware of the allegation, the DON and administrator did not report the incident to law enforcement or the State Agency as required by facility policy, citing the resident's history of making false accusations. The facility's policy mandates immediate reporting of all abuse allegations, but this was not followed.
The facility did not maintain verifiable 24-hour licensed nursing coverage, as required, when only an RN's presence could be confirmed for a shift and the hours worked by a contract LPN could not be substantiated through timesheets or other auditable records. This deficiency had the potential to affect all residents in the facility.
The facility did not ensure RN coverage for at least 8 consecutive hours per day, 7 days per week, on six occasions over a three-month period, potentially affecting all residents. Staffing schedules and timesheets showed gaps in RN presence, despite daily review and discussion of staffing needs by the DON and administrator.
Surveyors identified that dietary staff failed to consistently wear required hair and beard nets while preparing and serving food, and that a refrigerator in the dining area was dirty with undated food items and spills. Additionally, expired chlorine test strips were used to monitor the dishwasher's chemical levels, contrary to facility policy. Staff interviews confirmed awareness of these requirements and lapses in compliance.
The facility did not ensure adequate RN coverage on multiple days and failed to verify the presence of required nursing staff through available documentation, resulting in unaddressed gaps in staffing and incomplete facility-wide assessment of resource needs.
The facility did not electronically submit complete and accurate direct care staffing information to CMS, as required, using payroll and other verifiable and auditable data.
A nurse failed to disinfect a glucometer after use on a resident and did not follow proper contact time with disinfectant wipes, leading to potential cross-contamination. Additionally, the facility did not accurately document staff illness absences, return-to-work dates, or clearance procedures for two staff members, as required by policy.
A resident's request to change code status from full code (CPR) to DNR was not updated in the electronic medical record, leaving the dashboard in the PCC system incorrectly showing full code. Both an LPN and the DON confirmed reliance on the dashboard for code status during emergencies, and the discrepancy was acknowledged after review of the signed POLST and system records.
Two residents identified as high risk for elopement were able to leave the facility without proper supervision, one undetected for an hour despite a wander guard, due to missed safety checks, lack of staff communication, and inadequate training for both regular and agency staff. Non-nursing staff, such as dietary personnel, were not informed of residents' elopement risks and allowed a resident to exit unsupervised, with alarms ignored and care plan requirements unmet.
A resident who was cognitively intact, independent in a wheelchair, and assessed as low risk for elopement was unable to freely enter and exit the facility due to a locked entrance requiring staff assistance. The resident expressed frustration about feeling confined, and the facility's policy applied the same restrictions to all residents regardless of elopement risk.
Contracted care staff began working without completing required training or having access to EMR and resident care plans. A nursing assistant started her shift without prior training or access to care plans, and the DON confirmed the lapse. Facility policy did not address EMR access or training on key procedures, potentially impacting all residents.
A resident with moderate dementia and a history of unsafe wandering was able to leave the facility unnoticed on multiple occasions, including one incident where the individual removed a Wanderguard device and was found by a community member several blocks away. Staff failed to document or investigate these elopements, did not update the care plan or interventions, and did not notify family members. Facility policy requiring assessment, individualized care planning, and post-elopement procedures was not followed.
A resident with moderate cognitive impairment and a history of elopement was able to leave the facility undetected on multiple occasions by removing a wanderguard, with staff failing to document, investigate, or report these incidents as required by facility policy. Interviews confirmed staff awareness of the resident's elopement risk, but no formal investigation or state agency notification occurred.
A resident with a known history of wandering and elopement risk was able to remove his WanderGuard and leave the facility without staff knowledge, remaining missing for about an hour before being returned by police. The incident was not documented in the medical record or incident reports, nor was it reported to the State Agency, despite facility policy requiring such reporting for unauthorized departures. Staff interviews confirmed awareness of the resident's risk, but the event was not recognized as an elopement by facility leadership.
During an RSV outbreak, the facility did not consistently implement transmission-based precautions or conduct active respiratory symptom screening for residents. Several residents with respiratory symptoms and positive RSV tests were not isolated or monitored according to infection control protocols, and staff did not always use PPE or enforce mask use. Facility leadership and staff interviews revealed gaps in awareness, surveillance, and adherence to infection control policies, contributing to the spread of RSV among residents.
Two residents with significant fall risks experienced multiple falls, including one resulting in a subdural hematoma and hospitalization, due to the facility's failure to conduct comprehensive fall risk assessments, root cause analyses, and timely care plan updates. Interventions were inconsistently implemented and not individualized, and staff were unclear about supervision requirements and documentation, leading to inadequate fall prevention.
A resident with multiple sclerosis, sepsis, and acute ischemia of the intestine experienced a decline in condition, including nausea, vomiting, and diarrhea. The RN failed to perform an assessment or take vital signs, and did not contact a provider. The resident became unresponsive and CPR was initiated but stopped before EMS arrived. The facility did not notify the provider of the resident's deterioration, leading to the resident's death.
The facility did not employ a full-time DON, affecting all 36 residents. The DON was present only two to three times weekly and did not track her attendance. She acknowledged management challenges, and the administrator was aware of the full-time requirement but did not comply.
The facility failed to provide orientation and training to agency nurses, as required by its policy. Three RNs reported not receiving orientation to the facility or its policies, despite often being the only nurse on duty. The DON and administrator acknowledged the lack of a structured orientation process, and no evidence of orientation was provided, affecting the care of 36 residents.
The facility failed to maintain a safe and sanitary environment due to issues with flooring transitions, including broken tile and frayed carpet at a resident's room entrance, and missing transition pieces between carpeted and wood floors in hallways. These deficiencies posed potential risks for injury and infection control concerns. The maintenance director and administrator were aware of the issues, but no effective solutions were implemented, and no work order requests were submitted for the deficiencies.
The facility failed to ensure dignified meal assistance for residents dependent on staff for eating. Nursing assistants were observed standing and conversing while feeding residents with conditions like multiple sclerosis and cognitive impairment. The facility's policy lacked guidance on maintaining dignity during meal assistance, and staff were unclear about the protocol, contributing to the deficiency.
A resident's MDS was inaccurately coded, indicating discharge to a hospital instead of an assisted living facility. The RN responsible admitted the mistake and planned to correct it. The administrator expected accurate MDS records, but no policy on MDS accuracy was provided.
A resident with severe cognitive impairment and hearing loss experienced negligence when a staff member failed to remove her hearing aid during a shower, resulting in damage. The facility lacked proper documentation and procedures for managing hearing aids, leading to the resident's inability to hear well and uncertainty about the location of the damaged device. Staff interviews revealed a lack of awareness and communication regarding the resident's needs.
A resident with chronic pain syndrome did not receive prescribed lidocaine patches for nine days due to a failure in communication and follow-up by facility staff. The medication aide could not locate the patches, and the LPN was unaware of the issue. The DON confirmed that proper procedures were not followed, including contacting the pharmacy and notifying the physician. No policy was provided by the facility.
A facility failed to implement pharmacy recommendations to adjust medication administration times for a resident with multiple diagnoses, including schizoaffective disorder and thyroid disorder. Despite a pharmacist's advice to separate the administration of calcium carbonate and levothyroxine by four hours to avoid interactions, the resident's MAR showed consistent administration at the same time over several months. Interviews revealed that staff did not clarify or act on these recommendations, leading to a deficiency in medication management.
The facility failed to offer pneumococcal PCV-15 or PCV-20 vaccinations to two residents, as per CDC recommendations. One resident's records showed previous vaccinations but lacked documentation of being offered the newer vaccines. Another resident had consented to vaccination, but there was no evidence of administration. The facility's policy required offering the vaccine within 30 days of admission and providing information on benefits and side effects.
A facility failed to assess and identify appropriate mechanical lifts and slings for residents, leading to an incident where a resident fell during a transfer. The resident, with a history of Alzheimer's and a leg amputation, was not properly assessed for sling size, and staff used available slings without ensuring they were suitable. Interviews revealed inconsistencies in sling usage and a lack of proper measurement, contributing to the deficiency.
The facility failed to verify the professional licensure of a staff member hired as an RN, who did not hold an RN license and had a suspended LPN license. The staff member falsely claimed to have an RN license and worked as a trainee under supervision. The DON discovered the issue and contacted the police department.
The facility failed to follow physician-ordered wound treatments and did not ensure appropriate infection control practices during wound care for two residents. The RN did not perform hand hygiene between glove changes, did not use a barrier for wound supplies, and did not follow the physician's orders for wound care. Interviews with staff confirmed these deficiencies.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to timely report an allegation of staff-to-resident sexual abuse to law enforcement and the State Agency as required by policy. A resident with a history of traumatic sexual abuse and intact cognition reported that a nursing assistant had inappropriately touched him during a bath, causing embarrassment. The incident was reported to the DON and ADON, who became aware of the allegation but did not report it to the appropriate authorities within the required timeframe. The DON conducted an internal investigation but withheld reporting due to the resident's history of making false accusations and questioning his own perception of the event. Multiple staff, including an LPN and the social service designee, were aware of the allegation and discussed it during a morning meeting. Despite the facility's policy requiring immediate reporting of all alleged violations, the administrator and DON chose not to report the incident to the State Agency or law enforcement, citing the resident's history of manipulation and falsehoods. The facility's policy specifically mandates reporting all allegations of abuse within two hours if the event involves abuse or results in serious bodily injury, but this protocol was not followed in this case.
Failure to Maintain 24-Hour Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide licensed nursing coverage for 24 hours a day as required, based on review of payroll and other verifiable data for one quarter. On a specific day, documentation showed that only one registered nurse was verifiably present for the shift, while the presence of a contract LPN could not be confirmed through timesheet punches or other auditable records. The assignment sheet and PBJ data indicated that both an RN and an LPN were scheduled and reported as working, but only the RN's hours could be substantiated. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility aimed to overstaff to meet resident needs. However, the facility was unable to provide contract staff timesheets to verify the LPN's presence for the shift in question. The facility's staffing plan required at least one RN or LPN per shift, but the lack of verifiable documentation for the LPN resulted in a failure to demonstrate compliance with 24-hour licensed nursing coverage, potentially affecting all 39 residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of 8 consecutive hours per day, 7 days per week, as required. Review of facility schedules and timesheets for January, February, and March 2025 revealed that there was no RN coverage on six specific days across the three months. This deficiency had the potential to affect all 39 residents living in the facility. Interviews with the director of nursing (DON) and the administrator confirmed that staffing hours were reviewed daily and discussed in interdisciplinary team meetings, but gaps in RN coverage still occurred. The facility's policy required RN coverage as specified, and the DON could serve as a charge nurse when daily occupancy was 60 or fewer residents. The facility was also responsible for submitting accurate staffing data through the CMS payroll-based journal system.
Infection Control and Food Safety Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in infection control and food safety practices within the facility's dietary services. Dietary staff were found not wearing required hair nets and beard nets while preparing and serving food in the kitchen and dining areas. Specifically, a dietary aide was seen preparing drinks without a hair net, and a cook with a mustache and beard was repeatedly observed serving food without a beard net. Both staff members acknowledged the requirement for these protective coverings, with one stating unawareness of the need for a beard net and uncertainty about their availability. The dietary manager assistant confirmed that all dietary staff should be wearing hair and beard nets as needed during food service. Additionally, the central dining room refrigerator was found to be unclean, with pink juice spilled inside and a sticky, dark substance on the floor in front of it. The refrigerator contained undated individually wrapped sandwiches, and staff interviews confirmed that food should be dated and refrigerators regularly cleaned. There was also a failure to monitor the expiration of chlorine test strips used for checking the dishwasher's chemical levels, as expired strips were in use until discovered and replaced. Facility policies reviewed by surveyors required proper use of hair and beard restraints, routine cleaning and disinfection, and daily monitoring of dishwasher sanitizer levels.
Failure to Ensure Adequate RN Coverage and Accurate Staffing Documentation
Penalty
Summary
The facility failed to implement and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Review of staffing documentation for a specific date revealed discrepancies between the assignment sheet, PBJ data, and timesheet punches, with only one RN verifiably working and no way to confirm the presence of an LPN as documented. Additionally, contract staff timesheets were requested but not provided, further limiting verification of staffing levels. A review of facility schedules and timesheets over a three-month period identified multiple days with no RN coverage. Specifically, there were two days in January, three days in February, and one day in March without RN coverage. Interviews with the DON and administrator confirmed that staffing hours were reviewed daily and that the facility had implemented tracking of RN coverage and staff shortages. However, the facility assessment staffing plan only required one RN or LPN per shift, and there were documented gaps in RN coverage that were not addressed or verified through available records.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS. The information was required to be based on payroll and other verifiable and auditable data. This deficiency was identified through review of the facility's records and submission practices, which did not meet the required standards for accuracy and completeness as mandated by CMS.
Failure to Disinfect Glucometer and Incomplete Staff Illness Surveillance
Penalty
Summary
A registered nurse failed to properly disinfect a glucometer after use on a resident during a blood glucose check. After using the device, the nurse placed the used lancet in the sharps container and returned the glucometer to the treatment cart drawer without disinfecting it, despite the presence of another resident's glucometer in the same drawer. When questioned, the nurse admitted to forgetting to disinfect the device and subsequently used disinfecting wipes on both glucometers but did not allow the required wet contact time as per manufacturer instructions. The facility's policy required cleaning and disinfecting glucometers after each use, but this was not followed, and there was confusion among staff regarding the correct disinfection procedure and contact time. Additionally, the facility failed to maintain accurate staff illness surveillance records. For two staff members who called in sick, the illness logs and call-in reports did not document return-to-work dates, clearance procedures, or the number of days absent. The infection preventionist confirmed that the staff illness log and call-in forms were used for surveillance, but these forms lacked critical information. The director of nursing acknowledged the deficiencies in documentation and was unable to provide evidence of additional training or policy updates regarding staff illness surveillance.
Failure to Update Resident Code Status in EMR After Change to DNR
Penalty
Summary
The facility failed to update the code status in the electronic medical record (EMR) for one resident who had requested a change from full code (CPR) to Do Not Resuscitate (DNR). The resident's Provider Orders for Life-Sustaining Treatment (POLST), signed by both the resident and physician, reflected the change to DNR. However, the code status displayed on the resident's dashboard in the Point Click Care (PCC) system continued to indicate full code. Staff, including an LPN and the director of nursing, confirmed that they rely on the PCC dashboard to determine code status in emergencies, and both acknowledged the discrepancy between the POLST and the dashboard information. The director of nursing stated that the new order for DNR should have been entered into the system but was missed following the resident's request during a recent appointment. Audits of code status are conducted only a few times a year, and the last audit occurred prior to the resident's change in code status. The facility's policy outlines the process for determining and documenting code status upon admission and during care planning but does not specify how staff should confirm code status in the event of a need for CPR.
Failure to Provide Adequate Supervision and Accident Hazard Prevention for Residents at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and accident hazard prevention for two residents identified as being at risk for elopement. One resident, who had moderately impaired cognition and required a walker for mobility, was able to leave the facility undetected for approximately one hour despite wearing a wander guard. The resident exited through the locked front entrance, which was opened by an unknown responsible party with access to the door code. Staff were unaware of the resident's absence until notified by community members, and documentation revealed that required 15-minute safety checks were not completed as directed in the care plan. Interviews with staff indicated a lack of communication and training regarding elopement risks and required supervision. The nurse assigned to the resident was not aware of the need for 15-minute checks, and agency staff did not receive adequate orientation or access to care plans prior to their shifts. The resident was able to leave the facility by following a transportation driver out the door, and staff did not notice the resident's absence until contacted by external parties. The facility's internal investigation confirmed that staff were the only individuals with knowledge of the door code, and no staff admitted to allowing the resident to exit. A second resident, also identified as an elopement risk, was observed being allowed to exit the facility by a dietary staff member who was unaware of the resident's supervision requirements. The dietary staff member used the door code to let the resident outside, and the door alarm sounded, but the staff member did not respond appropriately. The DON confirmed that non-nursing staff did not have access to care plans and relied on verbal communication from supervisors to identify residents at risk for elopement. Facility policy required vigilant supervision and a systemic approach to monitoring residents at risk for elopement, but these procedures were not effectively implemented.
Failure to Allow Cognitively Intact Resident Free Entry and Exit
Penalty
Summary
The facility failed to ensure that a cognitively intact resident, who was not at risk for elopement, could freely enter and exit the facility. The resident, who had diagnoses including osteonecrosis and alcohol dependence, was assessed as a low elopement risk and was independent with locomotion in his wheelchair. Despite this, the facility kept the entrance door locked at all times, requiring staff assistance to unlock it or waiting for an automatic release after 15 seconds, as observed during multiple site visits. The resident was seen waiting at the entrance for staff to unlock the door and expressed frustration about feeling confined and having to sign in and out like a prisoner. The facility's policy on a restraint-free environment states that residents have the right to be treated with respect and dignity and to be free from physical or chemical restraints used for staff convenience. The director of nursing confirmed that the door locking policy was implemented due to the admission of more residents who wander, but this policy also applied to residents who were not at risk for elopement. The lack of a system to allow cognitively intact, low-risk residents to move freely in and out of the facility resulted in a failure to honor the resident's rights to self-determination and dignity.
Failure to Train and Provide EMR Access to Contracted Care Staff
Penalty
Summary
The facility failed to ensure that contracted resident care staff, specifically a nursing assistant, were competently trained on facility procedures and provided access to electronic medical records (EMR) prior to starting their shifts. One nursing assistant reported that on her first shift, she received no training and did not have access to any resident care plans until management arrived later in the morning. The director of nursing confirmed that the required training was not completed before the nursing assistant began working. Additionally, the facility's policy for contracted employees addressed emergency preparedness but did not include provisions for EMR access or education on other critical facility policies, such as those related to elopement. These failures had the potential to affect all 46 residents in the facility.
Failure to Assess and Supervise Elopement Risk Resulting in Resident Leaving Facility Unnoticed
Penalty
Summary
The facility failed to comprehensively assess and address the supervision needs and individualized interventions for a resident identified as an elopement risk. The resident, who had moderate dementia with behavioral disturbances, a history of delusional thinking, and was not safe to live independently, was admitted to the facility with clear documentation of cognitive impairment and safety concerns. Despite being identified as an elopement risk and having a Wanderguard device placed, there was no documented assessment or rationale for the use or changes of the Wanderguard, nor were there updates to the care plan or interventions following previous elopement attempts. On multiple occasions, the resident was able to leave the facility without staff knowledge. In one instance, the resident used a fingernail file to remove the Wanderguard and exited the building, later being found by a community member 12 blocks away, having crossed a major highway and railroad tracks. Staff interviews revealed inconsistent understanding of the resident's risk, lack of clear documentation of elopement incidents, and no comprehensive cognitive or safety assessments to determine the resident's ability to be unsupervised in the community. The facility did not complete incident reports, investigations, or care plan updates after these events, and family members were not notified of the elopements. Facility policy required a systemic approach to monitoring and managing residents at risk for elopement, including assessment, individualized care planning, and post-elopement procedures such as physical assessment, documentation, and family notification. However, these procedures were not followed, as evidenced by the lack of documentation, assessment, and communication after the resident's elopements. Staff interviews further indicated a lack of clarity regarding the resident's supervision needs and the purpose of the Wanderguard, contributing to the failure to prevent the resident from leaving the facility unsupervised.
Failure to Implement Elopement and Abuse/Neglect Policies
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation and Elopements and Wandering Resident policy for a resident with a history of elopement. The resident, who had moderate cognitive impairment and was independent with activities of daily living, was observed wearing a wanderguard but reported having previously cut off the device and left the facility on multiple occasions. The resident described using a fingernail file to remove the wanderguard, leaving the facility undetected, and being found by police after walking a significant distance. The resident also stated intentions to elope again and described previous successful attempts, including one where he was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record revealed a lack of documentation regarding the reported elopement attempts. Facility incident reports did not include any risk management, incident reports, or investigations related to these events. Additionally, the state agency's reporting center had no record of facility-reported incidents for the resident's elopement attempts. Interviews with staff confirmed awareness of the resident's elopement risk and recounted the events of the most recent elopement, including the resident being found by police far from the facility. Staff also noted the resident's pattern of waiting for opportunities to leave undetected. Despite the facility's policy requiring immediate investigation and reporting of suspected neglect or elopement, the incidents were not investigated or reported to the state agency. The DON and administrator both indicated that they did not consider the events to be elopements and therefore did not initiate investigations or reporting, even though the resident had left the facility without staff knowledge. The facility's policy outlines specific procedures for investigation, documentation, and reporting, none of which were followed in these instances.
Failure to Recognize and Report Resident Elopement
Penalty
Summary
The facility failed to recognize and report an elopement incident involving a resident identified as being at risk for elopement. The resident, who had a history of wandering and elopement attempts, was able to remove his WanderGuard bracelet using a fingernail file and left the facility without staff knowledge. He was gone for approximately an hour before being located by police and returned to the facility. The resident reported that he had previously eloped from the facility a couple of months prior, also by removing his WanderGuard, and was gone for about 20 minutes before staff noticed his absence. Review of the resident's medical record and facility incident reports revealed a lack of documentation regarding these elopement attempts. There were no risk management or incident reports related to the events, and the Minnesota Adult Abuse Reporting Center did not have any facility-reported incidents for the resident's elopement attempts. The resident's elopement risk assessment indicated multiple risk factors, including a history of wandering, family concerns, and medications that could cause confusion, but interventions in place were limited to recreational activities, a check-in/out log, staff awareness, room personalization, and a WanderGuard. Interviews with staff, including nursing assistants, an RN, the DON, and the administrator, confirmed that the resident was considered an elopement risk and that staff were aware of his tendencies. Despite this, the incident was not reported to the State Agency, as the facility's leadership did not initially consider the event to be an elopement. The facility's own policy defined elopement as a resident leaving the premises without authorization or necessary supervision, and required immediate reporting of such incidents, but this protocol was not followed.
Failure to Implement Infection Control Measures During RSV Outbreak
Penalty
Summary
The facility failed to implement effective infection prevention and control strategies for respiratory protection, specifically in response to an outbreak of Respiratory Syncytial Virus (RSV). Despite the onset of symptoms and positive RSV test results among multiple residents, the facility did not consistently initiate transmission-based precautions (TBP), such as isolation or droplet/contact precautions, at the onset of symptoms. For example, one resident with significant comorbidities including morbid obesity, COPD, and heart failure, developed respiratory symptoms and tested positive for RSV, but was not placed on appropriate precautions or monitored for ongoing symptoms. The care plan and physician orders did not reflect the need for TBP, and isolation was discontinued prematurely without a respiratory assessment to confirm symptom resolution. Several other residents developed respiratory symptoms and tested positive for RSV, yet their records did not show evidence of respiratory symptom screening, timely implementation of TBP, or consistent monitoring. In some cases, symptomatic residents were not isolated, and staff did not use personal protective equipment (PPE) when providing care. Residents with confirmed or suspected RSV were observed participating in communal dining and activities without masks, and staff failed to enforce isolation or mask use. The facility also lacked active screening protocols for early identification of new cases, and there was no comprehensive respiratory assessment or surveillance log tracking the spread of illness among residents. Interviews with facility leadership and staff revealed a lack of awareness and adherence to infection control policies and CDC guidelines. The Director of Nursing (DON) and Infection Preventionist were not fully informed about the outbreak status, did not conduct contact tracing, and were unaware of the number of cases that constituted an outbreak. Staff were not consistently educated or directed to monitor for respiratory symptoms, and there was no systematic process for implementing or removing TBP. The medical director was not notified of the outbreak in a timely manner, and the facility's infection control policies were not followed, resulting in a system-wide failure to prevent the spread of RSV.
Failure to Assess and Implement Comprehensive Fall Prevention Measures
Penalty
Summary
The facility failed to comprehensively assess and address fall risks for two residents with a history of falls and significant medical vulnerabilities. One resident, who had a history of traumatic brain injuries and severe cognitive impairment, was admitted with multiple facial fractures and a traumatic brain injury. Despite being identified as high risk for falls on admission, there was no fall prevention care plan developed for this resident until after multiple unwitnessed falls occurred, including one that resulted in a subdural hematoma and hospitalization. The care plan did not include specific interventions or clearly defined supervision levels, and staff were unclear about the frequency and documentation of required checks. For this resident, incident reports and progress notes documented repeated falls, wandering, and self-transferring behaviors, but failed to include comprehensive fall analyses or root cause assessments. Interventions such as gripper socks, soft touch call lights, and frequent checks were inconsistently implemented and not reflected in the care plan. Staff interviews revealed confusion about the meaning and frequency of 'frequent checks,' and documentation of interventions was lacking. The care plan was not updated in a timely manner, and interventions were not individualized based on comprehensive assessments of the resident's needs, including toileting and supervision requirements. A second resident, also identified as high risk for falls due to multiple fractures, cognitive impairment, and inability to follow directions, experienced several falls. Incident reports and post-fall analyses were incomplete, lacking documentation of mental status, predisposing factors, and root cause conclusions. Interventions such as frequent checks, fall mats, and medication reviews were inconsistently documented and not incorporated into the care plan. The care plan did not reflect new interventions or comprehensive assessments to address the resident's individualized needs, including toileting and supervision. Staff and the DON confirmed that comprehensive analyses and root cause assessments were not consistently completed for each fall, resulting in inadequate fall prevention measures.
Failure to Assess and Notify Provider Leads to Resident's Death
Penalty
Summary
The facility failed to complete an assessment, including vital signs and general condition, when a change in condition was reported for a resident with multiple sclerosis, sepsis, and acute ischemia of the intestine. The resident required substantial assistance with all activities of daily living and was cognitively intact. Despite the resident's deteriorating condition, which included nausea, vomiting, and diarrhea, the registered nurse (RN) did not perform a physical assessment or take vital signs throughout the day. The RN was aware of the resident's condition from the morning but did not contact the provider, citing it was a Saturday. The situation escalated when the resident experienced a nosebleed and became unresponsive in the afternoon. The RN initiated CPR and called 911, but CPR was stopped before emergency medical services (EMS) arrived. The EMS staff found the resident in asystole, and CPR had been discontinued by the facility staff. The facility's documentation lacked evidence of notifying the provider about the resident's deterioration prior to her death. Interviews with staff revealed that the RN did not follow the facility's protocol for notifying changes in a resident's condition or the American Heart Association guidelines for CPR. The director of nursing and medical director both indicated that an assessment and communication with the provider should have occurred when the resident first showed signs of illness. The nurse practitioner confirmed that there was always a provider on-call to address residents' needs, contradicting the RN's decision not to contact a provider.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which had the potential to affect all 36 residents. Observations on two consecutive days revealed the absence of the DON in the facility. During interviews, the DON admitted to being present at the facility only two to three times per week and acknowledged not tracking her attendance. She stated her responsibilities included managing staff and ensuring compliance, but also mentioned challenges with management and leadership. The administrator confirmed awareness of the requirement for a full-time DON, yet the facility did not comply with this regulation.
Lack of Orientation for Agency Nurses
Penalty
Summary
The facility failed to provide adequate orientation and training to agency nurses, which is a requirement for individuals providing services under a contractual agreement. Three registered nurses (RN-A, RN-B, and RN-C) who worked at the facility through an agency reported that they did not receive any orientation to the facility or its policies and procedures. These nurses also mentioned that they were often the only nurse on duty during their shifts, which could potentially impact the quality of care provided to the 36 residents of the facility. The Director of Nursing (DON) and the facility administrator acknowledged the lack of a structured orientation process for agency staff. The DON was unsure if there was a specific process in place, while the administrator admitted that agency staff should receive orientation, a review of policies, and a tour on their first shift. However, the administrator was unable to provide evidence of such orientation for the agency nurses. The facility's orientation policy, dated 2023, mandates that all staff, including those under contractual agreements, must complete general orientation before having formal contact with residents, and documentation of this process should be maintained in personnel files. Despite requests, no evidence of orientation for agency staff was provided.
Deficiency in Maintaining Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment due to issues with flooring transitions in several areas. Observations revealed broken tile and frayed carpet at the entrance of a resident's room, which posed a potential risk for injury. The resident reported no incidents of getting caught on the frayed carpet with his wheelchair, but there was no plan in place to address the issue. Additionally, the transition areas between carpeted and wood floors in the hallways were missing plastic transition pieces, leaving uneven surfaces and exposed cement, which could pose a tripping hazard. Interviews with the maintenance director and administrator indicated awareness of the flooring issues, but there was no effective solution implemented to secure the transition pieces. The maintenance director acknowledged the difficulty residents and staff faced maneuvering over the transitions, which contributed to the pieces being ripped off. The administrator confirmed the potential risks associated with the uneven surfaces and missing tiles, recognizing the infection control concern. Despite the facility's policy requiring written work order requests, no such requests were submitted for the observed deficiencies, and there was no policy provided related to maintaining a safe and sanitary environment.
Failure to Ensure Dignified Meal Assistance for Residents
Penalty
Summary
The facility failed to ensure that residents were assisted with their meals in a dignified manner. Observations revealed that nursing assistants stood while feeding residents who were dependent on staff for meal intake, including three residents with various medical conditions such as multiple sclerosis, cognitive impairment, and malnutrition risk. The nursing assistants were seen standing and conversing with each other while feeding the residents, rather than sitting to provide a more dignified experience. The facility's policy did not explicitly mention the need for staff to provide dignity while assisting residents with meals. Interviews with staff and the Director of Nursing (DON) indicated a lack of awareness and clarity regarding the protocol for feeding residents. The DON acknowledged that typically staff should not stand while feeding residents, except in specific cases like supporting a resident's head. The facility was in the process of rearranging seating, which may have contributed to the confusion. The Meal Supervision and Assistance policy emphasized adequate supervision and a relaxing environment but did not address the importance of maintaining resident dignity during meal assistance.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident's discharge record. Specifically, the MDS for one resident was incorrectly coded to indicate a discharge to a short-term general hospital, while the resident was actually discharged to an assisted living facility. This discrepancy was identified during a review of the resident's care plan, which indicated the resident's intention to move back home and possibly transfer to another skilled nursing facility closer to home. The error was acknowledged by the registered nurse responsible for completing the MDS, who admitted to mistakenly coding the discharge status. The nurse recognized the need to correct the MDS and resubmit it with the accurate discharge information. The facility administrator expressed an expectation for the MDS to accurately reflect the resident's status. However, no policy related to the accuracy of the MDS was provided by the end of the survey.
Failure to Manage Resident's Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident, identified as R29, had her hearing aids appropriately managed, leading to damage and loss. R29, who was hearing impaired and used bilateral hearing aids, experienced an incident where a staff member failed to remove her right hearing aid during a shower, resulting in water damage. This negligence left R29 unable to hear well out of her right ear, and she was unsure of the location of the damaged hearing aid. Despite R29's severe cognitive impairment and her reliance on hospice services, the facility did not have a personal inventory sheet for her upon admission, and there was no documentation of her hearing impairment in the Minimum Data Set (MDS). Interviews with facility staff revealed a lack of awareness and communication regarding R29's hearing aids. The social services designee was informed of the missing hearing aid but was unsure if the administration had addressed the concern. The Director of Nursing (DON) acknowledged the absence of a procedure for handling damaged hearing devices and admitted that no personal inventory sheet was completed for R29. The facility's Personal Property policy required prompt investigation of complaints regarding resident property, but there was no specific policy related to hearing aids. The administrator expected staff to file a grievance for missing items, but this was not done in R29's case.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident diagnosed with Wernicke's encephalopathy, chronic pain syndrome, and dementia. The resident was prescribed lidocaine patches for chronic pain, which were not administered for nine consecutive days. During an observation and interview, a medication aide was unable to locate the lidocaine patches and confirmed they had not been delivered. The resident's medication administration record indicated that the patches were unavailable on multiple dates, yet there was no documentation of increased pain during this period. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed a lack of communication and follow-up regarding the missing medication. The LPN was unaware of the missing patches and stated that the medication aide should have notified the nurse if the medication was unavailable. The DON confirmed that the nurse should have contacted the pharmacy and notified the physician if the medication could not be delivered, as well as completed an incident report. However, there was no evidence of any such actions being taken, and the facility failed to provide a policy regarding the procedure for handling such situations.
Failure to Implement Pharmacy Recommendations for Medication Timing
Penalty
Summary
The facility failed to act upon pharmacy recommendations to modify the administration times of medications for a resident diagnosed with schizoaffective disorder, anxiety, chronic kidney disease, and thyroid disorder, who also had moderate cognitive impairment. The pharmacist had identified a potential interaction between Fibercon, calcium carbonate, and levothyroxine, recommending that these medications be separated by four hours to avoid interactions. Despite this recommendation, the resident's Medication Administration Record (MAR) showed that calcium carbonate was consistently administered at 8:00 a.m. alongside levothyroxine over several months. Interviews with the clinical pharmacist and the director of nursing revealed that the staff did not clarify or implement the pharmacy's recommendations, which could lead to potential interactions if continued long-term. The facility's policy on Gradual Dose Reduction of Psychotropic Drugs indicated that medication reviews should occur monthly and that modifications should be made to prevent adverse consequences related to medication interactions. However, the necessary changes were not made, resulting in a deficiency in the facility's medication management practices.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents, R24 and R33, were offered the pneumococcal PCV-15 or PCV-20 vaccination or provided with a declination form, as recommended by the CDC. For R24, the Significant Change Minimum Data Assessment (MDS) indicated that pneumococcal vaccinations were up to date, with records showing PCV-13 received on 12/21/15 and PPSV-23 on 12/20/18. However, there was no documentation to confirm that R24 had been offered or declined the newer PCV-15 or PCV-20 vaccines. For R33, the MDS indicated that pneumococcal vaccinations were not up to date, and despite consent being obtained in May 2024, there was no evidence that R33 had received the PCV vaccines. An interview with the director of nursing on 9/26/24 revealed that the facility planned to offer the vaccine to residents. The facility's policy, reviewed on 4/08/24, stated that they would determine residents' PCV status and offer the vaccine within 30 days of admission unless medically contraindicated or previously vaccinated, and provide information on the benefits and potential side effects. The policy also indicated that vaccines would be administered or re-vaccinated according to CDC recommendations.
Inadequate Assessment and Use of Mechanical Lifts
Penalty
Summary
The facility failed to assess and identify the appropriate mechanical lift and corresponding slings for residents based on their height and weight, affecting 10 residents who required total mechanical lifts for transfers. This deficiency was highlighted by an incident involving a resident who was being transferred from her bed to a wheelchair using a total mechanical lift. During the transfer, the resident moved in the sling, causing her to slide out and hit her head. Although the staff reportedly used the correct-sized sling, the facility did not verify the sling size or ensure the correct sling for the lift was used. The resident involved in the incident had a history of Alzheimer's disease, malnutrition, anxiety, depression, and a right leg below-knee amputation. She was dependent on staff for self-care needs and required a two-person transfer with a total body lift. However, her care plan lacked documentation of appropriate sling sheet sizes and measurements. The facility's records did not show any assessment to identify the correct sling size based on the resident's height and weight, nor did they ensure the sling was suitable for the lift used. Interviews with staff revealed inconsistencies in sling sizes used for residents and a lack of proper measurement for sling sheets. Staff were expected to use any available sling sheets for transfers, regardless of the resident's specific needs or the lift manufacturer's instructions. The facility had not ordered additional sling sheets from the manufacturer, and there was no process in place to assess residents for the correct size sling or to ensure that information from a safety assessment was included in the care plan. This lack of a systematic approach to sling usage and lift transfers contributed to the deficiency.
Failure to Verify Professional Licensure of Hired Staff
Penalty
Summary
The facility failed to ensure that a staff member hired as a registered nurse (RN) was not employed with a disciplinary action in effect against his professional license by the Minnesota Board of Nursing. The staff member, who was hired as an RN, did not hold an RN license and had a suspended licensed practical nurse (LPN) license. This deficiency had the potential to affect all residents in the facility. The director of nursing (DON) did not verify the professional licensure of the staff member before allowing him to begin employment. During the initial employment interview, the staff member claimed to hold an RN license, and upon hire, he signed the RN job description. However, the DON or designee failed to confirm the active RN licensure status before the staff member started working. It was later discovered that the staff member had never held an RN license and his LPN license was suspended. The DON discussed the findings with the acting administrator and contacted the police department. The staff member worked as a trainee from February 23 through February 26, shadowing licensed staff at all times and was never left unsupervised. On February 27, the staff member was scheduled to work a day shift but was directed to the DON's office upon clocking in. When asked about his RN license, the staff member falsely claimed to have one. The DON then informed him that a search of the nursing board website revealed that he did not have an RN license and that his LPN license was suspended. The facility did not provide a copy of the license verification policy when requested.
Failure to Follow Wound Care Protocols and Infection Control Practices
Penalty
Summary
The facility failed to follow physician-ordered wound treatments and did not ensure appropriate infection control practices during wound care for two residents. For the first resident, the registered nurse (RN) did not perform hand hygiene between glove changes, did not use a barrier for wound supplies, and did not follow the physician's orders for wound care. The RN also left the wound open to air without covering it as per the physician's instructions and did not address other wounds that required attention. The RN placed the wound kit back into a cupboard without disinfecting it, further risking cross-contamination. The second resident also experienced improper wound care. The RN did not use a barrier for wound supplies, placed wound cleanser on the floor without a barrier, and did not follow the correct procedure for cleaning the wound. The RN also failed to perform hand hygiene between glove changes and did not follow the physician's orders for wound care. The wound kit was again placed back into storage without proper disinfection. Interviews with staff and review of facility policies confirmed that the RN did not follow the expected procedures for wound care and infection control. The facility's Director of Nursing and Wound Ostomy Consultant Nurse Practitioner both stated that the RN did not adhere to the physician's orders and proper infection control practices, which could potentially slow down the healing process and increase the risk of infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Olivia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Renville Health Services | 10.8 mi | ★★★★★ | 6 | 0 |
| River Valley Health And Rehabilitation Center Llc | 17.5 mi | ★★★★★ | 8 | 0 |
| Buffalo Lake Health Care Center | 18.2 mi | ★★★★★ | 10 | 0 |
| Franklin Restorative Care Center | 18.7 mi | ★★★★★ | 13 | 0 |
| Clara City Care Center | 22.5 mi | ★★★★★ | 9 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Olivia Restorative Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.