Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Olivet Careview Home during CMS and state inspections, most recent first.
The facility failed to adhere to proper infection control practices, particularly in the use of PPE for residents under COVID-19 precautions and the implementation of Enhanced Barrier Precautions (EBP). Staff were observed entering rooms of COVID-19 positive residents without wearing N95 masks, and inconsistencies were noted in EBP signage and PPE usage for residents with indwelling medical devices. The infection preventionist and director of nursing acknowledged the need for improved staff education and compliance with infection control protocols.
A resident with severe cognitive impairment and multiple diagnoses was not consistently shaved as per their care plan, impacting their dignity. Despite the resident's preference and family assistance, staff interviews revealed confusion about responsibility for shaving, leading to visible facial hair on the resident. The facility's policy on ADL completion was not consistently followed.
A facility failed to properly assess a resident's ability to self-administer medication safely. The resident, with intact cognition and multiple diagnoses, was left with medications without confirmation of ingestion. The TMA relied on verbal confirmation from an RN instead of documented orders. SAM assessments were incomplete, lacking necessary documentation on the resident's understanding of medications and safety. The facility's policy requiring comprehensive assessment by the interdisciplinary team was not followed.
A resident with specific dietary preferences documented in their care plan did not receive the correct food items or portions during meals. Despite having intact cognition and specific dietary needs due to conditions like diabetes and Parkinson's disease, the resident's requests for certain food items and double portions were not consistently honored. Staff confirmed these omissions, which violated the resident's right to self-determination.
A facility failed to implement a comprehensive care plan for a resident with chronic UTIs, omitting documentation of the resident's history and treatment preferences. Despite recommendations to avoid Macrobid due to ineffectiveness, the resident was administered this antibiotic, contrary to their preference and previous medical advice. The Director of Nursing confirmed the care plan's lack of necessary documentation, which was expected per facility policy.
Two residents at a facility experienced deficiencies in pressure ulcer prevention and care. One resident, with a history of pressure injuries, was not consistently repositioned or offloaded as per their care plan, leading to prolonged periods in a wheelchair. Another resident developed a deep tissue injury on their heel, which was not previously identified by staff. The facility's failure to adhere to care plans and document interventions contributed to these issues.
A resident with severe cognitive impairment and a history of falls did not receive care-planned fall interventions, as their wheelchair was incorrectly positioned away from the bed, contrary to the care plan. Staff interviews revealed a lack of adherence to the care plan, increasing the resident's fall risk.
A resident with complicated feeding problems was assisted by an unqualified environmental services staff member during a meal. The resident required supervision and had a care plan outlining specific feeding strategies due to her impaired cognition and risk for altered nutrition. The facility did not employ paid feeding assistants, and the incident highlighted a gap in ensuring only qualified staff provided feeding assistance.
A facility failed to report and investigate sexual abuse incidents involving two residents, leading to repeated abuse. A resident with cognitive impairments and a history of inappropriate behavior touched another resident inappropriately on two occasions. Despite staff witnessing the first incident, it was not reported or investigated, and the resident's care plan lacked interventions for sexually inappropriate behaviors. The facility's abuse prohibition policy was not followed, contributing to the subsequent incident.
A facility failed to report an abuse allegation within the required timeframe. A resident, who was mildly cognitively impaired and legally blind, reported inappropriate touching by another resident. The incident was witnessed by an LPN and a culinary server, but it was not reported immediately. The ADON was informed days later, but no investigation or report to the state agency was made. The facility's policy required immediate reporting and investigation, which was not followed, leading to a deficiency.
A resident with cognitive impairments reported inappropriate touching by another resident, but the LTC facility failed to investigate the allegation. Despite the incident being witnessed and reported to the ADON, no investigation was conducted, violating the facility's abuse prohibition policy.
The facility failed to follow care plans for residents requiring assistance with ADLs, resulting in missed meals and inadequate support. One resident was left in bed during a staffing shortage, missing breakfast, while another was not assisted with eating despite needing help. Staff interviews confirmed care plans were not updated or followed, highlighting challenges in providing necessary care.
Infection Control Lapses in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to proper infection control practices, specifically in the use of personal protective equipment (PPE) for residents under COVID-19 precautions. Observations revealed that staff members entered the rooms of residents with active COVID-19 infections without wearing the required N95 masks, despite signage indicating the necessity of such precautions. For instance, nursing assistants were seen wearing regular masks instead of N95 masks while delivering meal trays and providing care to residents who were on transmission-based precautions due to COVID-19. Interviews with staff confirmed a lack of compliance with the expected PPE protocols, as they admitted to either forgetting to wear the correct mask or misunderstanding the requirements. Additionally, the facility demonstrated inconsistencies in implementing Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A nursing assistant was observed changing a resident's brief and repositioning them without wearing a gown, contrary to the facility's policy that requires both a gown and gloves for such activities. The infection preventionist and registered nurse manager acknowledged the inconsistency in signage and the challenges faced by staff in understanding and adhering to EBP requirements. The use of an orange magnet to indicate EBP was intended for resident dignity but led to confusion among staff and family members. The facility's policies on infection control and EBP were not effectively communicated or enforced, resulting in lapses in infection prevention measures. The infection preventionist and director of nursing recognized the need for ongoing education and training to ensure staff compliance with PPE protocols. The report highlights the facility's struggle with maintaining consistent infection control practices, particularly in the context of COVID-19 and EBP, which are critical for preventing the spread of infections among residents.
Failure to Maintain Resident Dignity Through Personal Hygiene
Penalty
Summary
The facility failed to ensure the removal of unwanted facial hair for a resident with severe cognitive impairment and multiple diagnoses, including dementia and anxiety disorder. The resident required substantial assistance for personal hygiene, including shaving, as indicated in their care plan. Observations revealed that the resident had visible facial hair on multiple occasions, despite their preference to be shaved. Interviews with family members and staff confirmed that the resident felt better when shaved, and the family often assisted with shaving during visits. Staff interviews indicated a lack of consistent adherence to the resident's care plan regarding shaving. Nursing assistants and registered nurses acknowledged that the care plan directed whether residents wanted to be shaved, but there was confusion about which shift was responsible for this task. The director of nursing expected staff to offer shaving if it was care planned and hair was visible, emphasizing that not being shaved could impact the resident's dignity. The facility's policy on activities of daily living directed staff to follow the care plan and treat residents with respect and dignity, which was not consistently followed in this case.
Failure to Properly Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to comprehensively assess a resident's ability to self-administer medication (SAM) safely. The resident, who had intact cognition and diagnoses including heart failure, high blood pressure, multiple sclerosis, and muscle weakness, was observed during a medication pass where the trained medication assistant (TMA) left medications with the resident without ensuring they were taken. The TMA was unsure of the location of the SAM assessment and relied on verbal confirmation from a registered nurse (RN) that the resident was allowed to self-administer medications, despite the lack of proper documentation in the medication administration record (MAR) and care plan. The resident's SAM assessments were incomplete, lacking documentation on whether the resident could identify medications, dosages, and potential side effects, and whether the interdisciplinary team deemed her safe to self-administer. The nurse manager acknowledged an error in the SAM assessment and confirmed the assessments lacked necessary documentation. The facility's policy required a comprehensive assessment by the interdisciplinary team to determine a resident's safety to self-administer medications, which was not followed in this case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which is a violation of the resident's right to self-determination. The resident, who had intact cognition and was diagnosed with high blood pressure, diabetes, high cholesterol, and Parkinson's disease, had specific dietary preferences documented in his care plan. These preferences included a diabetic diet with the option to request regular foods, specific breakfast items, and an evening snack of vegetables. However, the care plan lacked documentation on his preferences for larger or double portions at meals. Despite these documented preferences, the resident repeatedly did not receive the food items or portions he requested, as observed during multiple dining observations. During these observations, the resident was not served the correct portions or items as indicated on his meal ticket. For instance, he did not receive mashed potatoes, an apple fritter, or mandarin oranges as ordered. Staff confirmed these omissions and acknowledged that the resident should have received the items. The resident expressed dissatisfaction with the portions, stating they were insufficient and left him feeling hungry. The facility's policy on person-centered care planning required that each resident's care plan be individualized and reviewed regularly, but the facility failed to adhere to this policy, resulting in the deficiency.
Failure to Implement Resident-Specific Care Plan for Chronic UTIs
Penalty
Summary
The facility failed to develop and implement a comprehensive and resident-specific care plan for a resident with a history of chronic urinary tract infections (UTIs). The resident, who had intact cognition and was occasionally incontinent of urine, used an external catheter and had multiple diagnoses including high blood pressure, benign prostatic hyperplasia, diabetes, Parkinson's disease, and a history of UTIs. Despite these conditions, the care plan revised on October 4, 2023, lacked documentation regarding the resident's chronic UTIs and did not include interventions that reflected the resident's treatment preferences, such as avoiding the antibiotic Macrobid, which the resident reported as ineffective. The deficiency was further highlighted by a provider progress note from July 29, 2024, which recommended discontinuing Macrobid due to a possible chronic prostatitis component and suggested using Cipro instead. However, the resident's medication administration record from January 2025 showed that Macrobid was administered, contrary to the resident's preference and previous recommendations. Interviews with the resident and a family member confirmed ongoing discussions with the facility about the ineffectiveness of Macrobid and the preference for alternative treatments like Keflex. The Director of Nursing acknowledged the omission in the care plan, which was expected to include documentation of the resident's history of UTIs and treatment preferences, as per the facility's policy on person-centered care planning.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. One resident, identified as R28, had a history of pressure injuries and was at high risk for skin breakdown due to multiple health conditions, including severe cognitive impairment, diabetes, and peripheral vascular disease. Despite having a care plan that included interventions such as repositioning every two hours and offloading after meals, there were multiple instances where these interventions were not documented or carried out. Observations showed that R28 remained in a wheelchair for extended periods without being repositioned, and there was a lack of documentation regarding refusals to reposition or offload, which were supposed to be reported to the charge nurse. Another resident, R45, was also at risk for pressure ulcers due to conditions like morbid obesity and limited mobility. R45's care plan included interventions such as daily skin observation and the use of pressure-reducing devices. However, during an observation, a purplish-red discoloration was found on R45's right heel, indicating a deep tissue injury. This area had not been previously identified or documented by the staff, and it was discovered during routine care. The staff involved were not aware of the discoloration, and there was a lack of communication regarding R45's refusal to wear socks, which could have contributed to the pressure injury. The facility's failure to adhere to care plans and properly document and communicate skin assessments and interventions contributed to the development and risk of pressure injuries in these residents. The director of nursing acknowledged that not following interventions could lead to skin breakdown or worsening conditions, highlighting the importance of timely identification and implementation of preventive measures. The facility's policy required regular skin assessments and communication of care plans to staff, which were not consistently followed in these cases.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement care-planned fall interventions for a resident (R34) with a history of repeated falls and severe cognitive impairment. R34's care plan, which was revised recently, included specific interventions to prevent falls, such as ensuring the wheelchair was next to the bed to reduce fall risk if the resident attempted to self-transfer. However, during observations, the wheelchair was found facing away from the resident and out of reach, contrary to the care plan directives. Nursing assistants interviewed were either unaware of the specific fall interventions for R34 or did not follow them, as evidenced by the incorrect wheelchair placement. Interviews with nursing staff, including registered nurses and the director of nursing, revealed that staff were expected to follow the care plan and use the Kardex for guidance on fall interventions. Despite this expectation, the staff did not adhere to the care plan, as the wheelchair was not positioned correctly, increasing the risk of falls for R34. The facility's policy on falls and injuries indicated that care plans should reflect interventions to minimize falls, but this was not effectively implemented for R34, leading to the deficiency.
Unqualified Staff Assisting Resident with Feeding
Penalty
Summary
The facility failed to ensure that a resident with complicated feeding problems received assistance from qualified staff. During a dining observation, an environmental services staff member, ES-A, was seen assisting a resident, R112, with her meal. This resident had moderately impaired cognition and required supervision or touching assistance during eating, as indicated in her care plan. The care plan also highlighted her risk for altered nutrition status and outlined specific strategies for safe feeding, including the use of adaptive equipment and monitoring for signs of swallowing difficulties. Despite these requirements, ES-A, who was not a qualified feeding assistant, was observed feeding the resident. Interviews revealed that ES-A had received some prior training, but it was unclear if this training was at the current facility. The Director of Nursing confirmed that the facility did not employ paid feeding assistants and relied on nursing staff for dining assistance. The facility's policy stated that feeding assistants should only assist residents without complicated eating problems, which was not adhered to in this case. The Registered Nurse, RN-A, who witnessed the incident, acknowledged the need for further discussions with staff about handling such situations, as this was the first occurrence they had observed.
Failure to Report and Investigate Sexual Abuse Incidents
Penalty
Summary
The facility failed to report, investigate, and initiate interventions for sexual abuse, resulting in subsequent incidents involving two residents. On 7/6/24, a registered nurse (RN-A) failed to report an allegation that a resident (R2) had touched another resident (R1) inappropriately. Despite being informed by a licensed practical nurse (LPN-A) and a culinary server (CS) about the incident, RN-A did not notify a supervisor or the director of nursing (DON) because she did not believe the touching was intentional. This lack of action led to a second incident on 7/10/24, where R2 was again observed inappropriately touching R1. R1, who was mildly cognitively impaired with diagnoses including seizures, depression, schizophrenia, and legal blindness, was at risk for abuse due to vision loss. R2, who was severely cognitively impaired with diagnoses including traumatic brain bleed, paralysis, and vision and hearing loss, had a history of grabbing at people and objects. Despite these known behaviors, R2's care plan did not include interventions for sexually inappropriate behaviors until after the second incident. The facility's failure to report and investigate the initial incident on 7/6/24, as well as the lack of appropriate interventions in R2's care plan, contributed to the subsequent incident on 7/10/24. The facility's abuse prohibition policy required immediate reporting and investigation of such incidents, which was not followed. The director of nursing confirmed that the incident should have been reported and investigated, and a report should have been filed with the state agency.
Removal Plan
- Placed R2 on 1:1 supervision
- Initiated care plan changes and interventions for R2
- Initiated education to all staff members regarding vulnerable adult abuse reporting
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the State Agency. A resident, who was mildly cognitively impaired and legally blind, reported that a male resident had inappropriately touched her. This incident was witnessed by a Licensed Practical Nurse (LPN) and a culinary server, but neither reported it immediately to the appropriate authorities. The LPN informed the Assistant Director of Nursing (ADON) several days later, but no investigation was initiated, and no report was filed with the state agency. The Director of Nursing (DON) acknowledged awareness of the incident but did not have detailed information. The facility's policy required immediate reporting and investigation of such incidents, which was not followed. The policy specified that allegations of abuse should be reported to the state agency within two hours if they involved abuse, serious bodily injury, or suspicion of a crime. The failure to adhere to these procedures resulted in a deficiency in the facility's handling of the abuse allegation.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate allegations of abuse involving a resident, R1, who was mildly cognitively impaired and had diagnoses including seizures, depression, schizophrenia, and legal blindness. R1's care plan indicated a risk for abuse due to vision loss, with instructions for staff to follow vulnerable adult policies. On a specific date, R1 reported that a male resident, R2, who was severely cognitively impaired with traumatic brain bleed, paralysis, and vision and hearing loss, had inappropriately touched her. Despite this report, there was no investigation into the incident. The incident was witnessed by an LPN who reported it to the ADON, but no further action was taken to investigate the matter. The DON was aware of the incident but did not have details, and confirmed that the incident should have been investigated. The facility's abuse prohibition policy required an initial investigation to determine if the incident met criteria for reporting to the state agency, including interviewing involved parties and notifying the police if necessary. However, these steps were not followed, leading to a deficiency in handling the abuse allegation.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide services in accordance with the residents' written care plans for several residents who were dependent on staff for activities of daily living (ADLs). One resident, who had severe cognitive impairment and required assistance with eating and hygiene, was left in bed during a staffing shortage and missed breakfast. The resident's family member reported that the resident was not checked or changed during the night and was not assisted out of bed until late morning. Video evidence confirmed the lack of care provided during this period. Another resident with severe cognitive impairment and a risk for unintentional weight loss was observed sitting in the dining room with a full plate of food but was not assisted or cued to eat by staff. Despite the resident's care plan indicating the need for assistance with eating, staff failed to provide the necessary support, and the resident's care plan was not updated to reflect the current needs. Staff interviews revealed that the unit was challenging to work in due to the high level of care required by residents. A third resident, also with severe cognitive impairment, was observed not receiving the necessary assistance with eating, despite the care plan indicating the need for meal set-up and supervision. The resident was left alone with a meal tray and did not receive the required cues or assistance to eat. Staff interviews confirmed that the resident's care plan was not followed, and there was an expectation for staff to provide eating assistance to residents who required it.
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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.
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Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Olivet Home | 0 mi | — | 7 | 0 |
| Grand Avenue Rest Home | 1.7 mi | — | 9 | 0 |
| Edenbrook Of Edina | 1.7 mi | — | 15 | 0 |
| Lakehouse Healthcare & Rehabilitation Center | 2.2 mi | — | 5 | 0 |
| Aurora On France | 2.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.