Mountain View Memory Care.

“The medical evaluation for a resident did not include the medication regimen, contraindicated medications, and medication side effects. The evaluation indicated "See attached" but nothing was attached.”

“The support plan for a resident did not address the resident's need for psychiatric services, multiple falls resulting in lacerations and stitches, and how these needs will be met.”

“A resident was treated without dignity and respect when staff person A administered prescribed medications by pinching the resident's nose until the resident's mouth opened, forcing the resident to receive medication without consent. The resident verbally objected and was visibly upset by this method of medication administration.”

“Aversive conditioning was prohibited but was used when staff person A pinched the resident's nose (a noxious stimuli method) to force medication administration. This constitutes the application of a painful or noxious stimuli in violation of the aversive conditioning prohibition.”

“Carbon monoxide detectors required by the Care Facility Carbon Monoxide Alarms Standards Act of June 23, 2016 were not installed and maintained for three gas-operated furnaces located in mechanical rooms. No detectors were found in or immediately outside the point of egress for any of the three furnace locations.”

“Poisonous materials were not stored in original, labeled containers. A plastic lemon cleaner spray bottle with blue liquid labeled in magic marker was in the laundry room, an empty spray bottle labeled in magic marker was in the laundry room, and a purple liquid in an unidentified spray bottle was on a shelf in the kitchen next to the dining area.”

“Sanitary conditions were not maintained. Feces was found on the toilet seat and toilet paper roll in the common bathroom at the beginning of the 100 resident hall.”

“Trash in the kitchen was not kept in a covered receptacle. An uncovered, unattended 40-gallon gray plastic garbage can approximately half full of refuse was located in the kitchen approximately 6 feet from the food preparation area.”

“A surface was not maintained in good repair. The door sweep on the exterior side of the exit door to the mechanical room located on the far right of the great room was partially detached.”

“Windows were not securely screened. No window screen was found in the furthest left window located in the coffee café room.”

“The home failed to immediately report suspected abuse of a resident to the local Area Agency on Aging. Staff member A made a derogatory remark to resident #1 after the resident refused candy, and the home did not report this incident until a later date, despite multiple staff members having knowledge of it.”

“The home failed to immediately develop and implement a plan of supervision or suspend staff member A following an allegation of abuse. The staff member worked in the home without supervision or an approved supervision plan after the incident.”

“The home failed to report an incident involving suspected abuse to the Department within 24 hours. Multiple staff members observed resident #1 with bruises resembling abuse after a family visit, but the home did not report this incident to the Department.”

“The home failed to immediately report suspected abuse of a resident to the local Area Agency on Aging. Staff member A made a derogatory remark to resident #1 after the resident refused candy, and the home did not report this incident until a later date, despite multiple staff members having knowledge of it.”

“The home failed to immediately develop and implement a plan of supervision or suspend staff member A following an allegation of abuse. The staff member worked in the home without supervision or an approved supervision plan after the incident.”

“The home failed to report an incident involving suspected abuse to the Department within 24 hours. Multiple staff members observed resident #1 with bruises resembling abuse after a family visit, but the home did not report this incident to the Department.”

“The home failed to immediately report suspected abuse of a resident to the local Area Agency on Aging. Staff member A made a derogatory remark to resident #1 after the resident refused candy, and the home did not report this incident until a later date, despite multiple staff members having knowledge of it.”

“The home failed to immediately develop and implement a plan of supervision or suspend staff member A following an allegation of abuse. The staff member worked in the home without supervision or an approved supervision plan after the incident.”

“The home failed to report an incident involving suspected abuse to the Department within 24 hours. Multiple staff members observed resident #1 with bruises resembling abuse after a family visit, but the home did not report this incident to the Department.”

“The facility received a phone call on 2/12/24 at approximately 8:00 p.m. from a third-party person indicating video evidence of staff person A verbally abusing resident #1 and throwing the resident's baby doll. This allegation of abuse was not immediately reported to the local Area Agency on Aging.”

“On 2/12/24 at approximately 8:00 p.m., the facility received a phone call regarding video evidence of staff abuse of resident #1. The facility did not report this incident to the Department until 2/14/24, failing to meet the 24-hour reporting requirement.”

“Resident #1's assessment and support plan indicates the resident requires a Hoyer lift and 2 staff persons for all transfers/mobility. On 2/12/24 at approximately 2:30 p.m., staff person A transferred resident #1 from a Broda chair to bed and back without using a Hoyer lift or the assistance of an additional staff person.”

“Staff person A transferred resident #1 without required Hoyer lift and two-person assist, then recorded the resident on a personal mobile phone and sent the recording to an outside third-party while calling the resident derogatory names and throwing the resident's baby doll across the room.”

“Staff person A used a personal mobile phone to record resident #1 in the resident's bedroom and sent the recording to a third-party person outside the facility, violating the resident's right to privacy. This is a repeat violation from 6/6/22.”

“Resident #1 requires total physical assistance with toileting needs per assessment and support plan, but did not receive required assistance on numerous occasions in August 2023. Staff reported resident's briefs, clothing, and bedding were regularly soaked during morning hygiene care. Resident #2 similarly did not receive required overnight incontinence assistance on numerous occasions in August 2023, with staff reporting same conditions.”

“When Resident #3 required assistance with toileting, a staff person responded by yelling profanities and insults, stating 'Why the fuck did you do this? You're doing this out of spite. We have a million things to do, and you are wasting our time.' The resident was found crying and reported hating the staff person because they made her feel bad.”

“Resident #4 exhibited aggressive and combative behavior preventing staff from providing care, and the home did not implement positive interventions to modify or eliminate the behavior. The resident regularly refused showers (showered only 4 times over 6 weeks), refused catheter care resulting in painful redness and odor, engaged in fecal smearing on body, walls, food, sheets, and furniture, and threw feces at staff.”

“Resident #5's assessment did not address fall risk despite the resident having fallen on multiple dates including: a fall resulting in fractured wrist, an unwitnessed fall in a bathroom, a fall in the great room, and a fall resulting in hospitalization and diagnosis of a left parietal region injury after tripping over a scale.”

“Resident #4's initial medical evaluation does not include pulse rate, blood pressure, temperature, and cognitive functioning (these sections are blank). The documentation also does not include a diagnosis of Alzheimer's disease or other dementia as required. This is a repeat violation from 3/22/2023.”

“Posted menus did not indicate specific dates for the current and upcoming week, although they showed Week 1-Week 4 spring/summer menus without dates.”

“On the inspection date, 37 residents with mobility needs required a minimum of 74 hours of direct care staffing, but only 72.5 hours were provided. This was a repeat violation from 3/22/23.”

“On the inspection date, 37 residents with mobility needs required a minimum of 55.5 hours of direct care staffing during waking hours, but only 51 hours were provided during waking hours. This was a repeat violation from 3/22/23.”

“A one-liter bottle of Equaline Antiseptic mouth rinse and a tube of Medline Calazime ointment were found unlocked, unattended, and accessible in resident bathrooms. Both items had warnings on the manufacturer's label regarding accidental ingestion.”

“Resident #3's bedroom had a soiled incontinence brief draped over the bedside table, and the bathroom trash can was full of soiled briefs and wipes and lacked a lid.”

“Resident #3's fitted bed sheet had multiple smears of feces and urine, indicating bed linens were not clean and in good repair.”

“A couch was found in front of an emergency exit located between the 200 and 300 hallways, obstructing the egress route.”