Olivia Restorative Care Center: Medication Errors - MN
The patient, identified in inspection records only as Resident 11, had been discharged from a hospital on August 15, 2025. His physician had written discharge orders specifying what medications he needed and at what doses. When those orders were transcribed into the facility's electronic records, something went wrong, five times. A licensed practical nurse entered the orders. A second licensed practical nurse, identified in the report as LPN-C, was supposed to catch any mistakes as part of the facility's own double-check process.
LPN-C told inspectors she had reviewed Resident 11's admission orders and did not see the errors.
The facility's own procedures required a second nurse to sign off in what the policy called a "SECOND CHECK BOX" before orders were considered complete. That check happened. It didn't work.
By the time a nurse practitioner identified in the report as NP-A learned about the errors during a visit on August 19, Resident 11 had already missed eight doses of calcium acetate at the correct amount. NP-A reviewed the medication list with the director of nursing and corrected it to match the physician's hospital discharge orders.
Calcium acetate is used in dialysis patients to control phosphate levels in the blood. When phosphate builds too high, it pulls calcium from bones and can damage the heart and blood vessels over time. Resident 11 was scheduled for dialysis the following day. NP-A told inspectors that labs would be checked at that point for calcium and phosphate levels to assess what the eight missed doses had done.
NP-A's stated expectation, according to the inspection report, was that staff transcribe and verify medication orders exactly as written by the physician, and contact NP-A or the attending physician if anything was unclear.
That did not happen here.
The facility had written policies on exactly this process. The medication orders policy required that every order include the medication name, dose, route, frequency, and administration time. It required each order to be documented with a date, time, and signature. It required newly prescribed medications to be transcribed onto the medication administration record and verified in the electronic system for accuracy.
The order process procedure laid out fifteen numbered steps, including the double-check requirement.
Inspectors rated the violation as causing actual harm.
What's notable is not that a transcription error occurred. Transcription errors happen in healthcare settings, and double-check systems exist specifically because of that reality. What inspectors documented here is that the double-check system failed completely. The second nurse signed off. The errors stayed in the record. Resident 11 took the wrong doses for more than a week before a nurse practitioner caught it during a routine visit.
NP-A told inspectors his labs would be reviewed at dialysis. The inspection report does not say what those labs showed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Olivia Restorative Care Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
OLIVIA RESTORATIVE CARE CENTER in OLIVIA, MN was cited for violations during a health inspection on August 20, 2025.
The patient, identified in inspection records only as Resident 11, had been discharged from a hospital on August 15, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.