Brookdale Mariana Butte

“Based on interview and record review, the residence failed to provide residents with lift assistance when determinedappropriate instead of relying on emergency medical responders, affecting two of six (#2 and #3). Findings include:1. Residence policyThe Lift Assistance policy, dated 2/2022, read in part:"To maintain quality care standards for our residents who experience a fall, the community will follow this policy and the Falls Checklist to determine when it is appropriate for an associate to assist a resident who has fallen and when local emergency medical responders should be contacted. If the resident is free of pain, able to move without pain or difficulty, and/or there is no change from baseline, the resident ' s mental status is unchanged from baseline, and there is no or minor bleeding or requests to be assisted to a standing position, the associate will physically perform the lift assistance using techniques provided in associate training and monitor the resident."The Health and Wellness Director (HWD)/nurse/Executive Director (ED)/or designee should call 911 if the resident:a. complains of pain, before or after attempting lift assist,b. experiences difficulty moving,c. has loss of consciousness,d. has a physical or mental decline from baseline,e. experiences a head injury,f. is bleeding,g. requests 911 be called or refuses lift assist,h. is found unresponsive outdoors in extreme weather."2. Record reviewResident #2 was admitted to the residence on 2/7/24, diagnoses included hypertension.A progress note, dated 11/6/25, revealed Resident #2 had a witnessed fall in his apartment and the residence contacted non-emergency services for lift assist. 3. InterviewOn 12/22/25 at 10:30 a.m., Resident #3 stated that on Saturday, 12/20/25, he fell in his bathroom while transitioning from the toilet to his wheelchair. Resident #3 stated the caregiver "couldn't help me get up," and paramedics were subsequently called to perform a lift assist. The resident noted he was not injured and stated that the paramedics "complained they see me too much" for these types of calls.On 12/22/25 at 11:20 a.m., Resident #2 said he fell in the bathroom while a caregiver was present (date unknown by resident). Resident #2 said he misjudged the distance of his wheelchair and ended up on the floor. Resident #2 said emergency medical response services (EMS) came out and "helped him up off the floor". Resident #2 said he was not injured or in pain when EMS was called. On 12/22/25 at 4:31 p.m., Staff #1 stated she called emergency medical services anytime a "bigger resident fell" after she injured herself lifting a resident in the past. Staff #1 said she called 911 for non-emergency lift assistance whether the residents were injured or not. On 12/22/25 at 5:48 p.m., the administrator reviewed the progress note for Resident #2, dated 11/6/25, and stated EMS should not have been called. The administrator stated that it was not appropriate to contact emergency responders for a lift assistance and that emergency services should not be called unless there is an injury, such as "hitting the head, bleeding, unconsciousness, pain, or a change in baseline." 4. Similar deficient practice occurred with Resident #3.”

“Based on observation and interview, the residence failed to ensure a physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 25 current residents. Findings include:During the environmental tour on 9/10/24 at 9:37 a.m., the secured environment reception area, that all secure environment residents had access to, had carpets, chairs, and loveseats with stains. The carpet and love seat had several brown stains with a diameter of a half inch. The chair closest to the entrance door had a brown stain with pebble-like pieces of desiccated mass. On 9/10/24 at approximately 10:00 a.m., Staff #4 acknowledged the stains on the carpet, loveseat, and chair were unsanitary. On 9/10/24 at approximately 10:30 a.m., the regional health and wellness director and the administrator acknowledged the stains on the carpet, loveseat and chair were unsanitary.”

“Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting four of four sample residents (#1-#3,#9) whose medications were administered.Findings include:On 9/10/24 at 7:37 a.m., Staff #4 washed her hands, walked over to the medication room, touched multiple keys on the key rings, unlocked the medication room, touched the door knob, unlocked the medication cart, touched the laptop, medication pack, and the medication cup. Staff #4 touched the door knob, closed the medication room door, set the key rings on the dining table and proceeded to administered the medications to Resident #2. Staff #4 repeated the previously described medication administration for Resident #1, #3 and #9.On 9/10/24 at approximately 11:30 a.m., the regional health and wellness director (RHWD) said she expected staff to wash or sanitize their hands before each medication administration. The RHWD stated she expected staff to sanitize their hands before touching the medication pack and administering medications.”

“Based on observation and interview, the residence failed to ensure the secure outdoor area was available year-round and independently accessible to residents without staff assistance for entrance or exit, affecting 25 current residents. Findings include:On 9/10/24 at approximately 9:00 a.m., Resident #9 and three residents tried to access the outdoor secured environment but the door was double locked. The outdoor secured area was inaccessible to residents who tried to access the secured area without the assistance of staff. On 9/10/24 at approximately 9:15 a.m., Staff #3 stated the residence locked the main entrance door to the secured outdoor area because Resident #9 tried to elope. Staff #3 was unaware the residence was required to provide a year-round outdoor area that residents in the secure environment could independently access.On 9/10/24 at approximately 2:00 p.m., the regional health and wellness director and the administrator were unaware of the regulation that residence was required to provide a year-round outdoor area that residents in the secure environment could independently access.”