Butterfield Trail Village

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to maintain the manufacturer's integrity of a sealed controlled medication prescribed for a resident and securely stored by the facility for 1 (Resident #1) of 7 Residents reviewed for personal property, specifically a sealed bottle of liquid opioid pain medication recorded and stored by staff nurses, was opened and missing part of its contents without the request of, or assessed need for, the prescribed resident. The findings include: A review of a facility policy titled, Storage of Medications, revised April 2007, indicated, Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to dispense a pharmacy bubble packaged pain medication according to professional standards for 1 (Resident #3) of 3 residents reviewed for pharmacy services. Findings include: During an observation of a medication administration pass on 01/09/2025 at 7:54 AM, Licensed Practical Nurse (LPN) #1 pulled a pain medication card for Resident #3 and questioned why the pharmacy packaged two tablets in each bubble pouch when the order was for one. One bubble pouch was opened, and one tablet was gone, but one tablet remained. LPN #1 unsuccessfully attempted to call pharmacy and investigate. A review of the admission Record indicated the facility admitted Resident #3 with diagnoses that included dementia, cognitive communication deficit, age-related physical debility, and osteoarthritis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2024, revealed Resident #3 had a Staff Assessment of Mental Status (SAMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure dignity was maintained when providing wound care for 1 resident (Resident # 42) and when administering an insulin injection for 1 resident (Resident # 11). Findings include: A review of a facility document titled, Patient's [NAME] of Rights, undated, indicated, .2. Will be treated with consideration, respect, and full recognition of his/her dignity and . including privacy in treatment and in care of my personal needs . 9. Is assured confidential treatment of his/her personal and medical records .15. May have needs .accommodated .staff behaviors to assist residents in maintaining .dignity . 1. A review of the Detailed Summary, indicated the facility admitted Resident #42 with a diagnosis that included Alzheimer's Disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2024 revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Section…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure oxygen was administered only when ordered by a physician to prevent potential respiratory complications for 1 (Resident #9) of 1 sampled resident. The findings are: A review of a facility policy titled, Medication and Treatment, dated July 2016 indicated, .1. Medications shall be administered only upon the written order of a person licensed and authorized to prescribe such medications in this state. A review of a facility policy titled, Medication Orders, dated November 2014 indicated, .3. Oxygen orders - When recording orders for oxygen, specify the rate of flow, route, and rationale . A review of Resident #9's Detailed Summary form indicated the facility admitted Resident #9 on 10/27/2009 with coronary obstructive pulmonary disease, and congestive heart failure. A review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024, documented Resident #9 scored 15 (13-15 indicates cognitively intact) on a Brief Interview for mental Status (BIMS) and received oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to maintain infection control practices as evidenced by wound care being provided to a resident sitting at a dining table for 1 (Resident # 42) of 1 resident observed with wounds. Findings include: A review of a facility document titled, Infection Control Goals of Infection Control and Prevention, undated, indicated, .2. Minimize opportunity for transmission of pathogens. 3. Apply current scientifically accepted infection prevention and control principles appropriate for the specific work environment .The Chain of Infection .The mode in which the organism travels to infect others .All environmental and working surfaces must be promptly cleaned and decontaminated after contact with blood or OPIM (other potentially infectious materials) .Transmission of infections is largely via hand contact with a surface . disinfecting environmental surfaces is fundamental to reducing infections . A review of the Detailed Summary, indicated the facility admitted Resident #42 with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure food items stored in the refrigerator, freezer and dry storage areas were sealed or covered; the ice machine was maintained in a clean and sanitary condition, and expired food items and drinks were promptly removed from stock to prevent the potential for bacteria growth for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 40 residents who received meals from the kitchen (total census: 40), as documented on a list provided by the Administrator on 05/25/23 at 7:45 AM. The findings are: 1.On 05/22/23 at 10:55 AM, in the Dry Storage Room of the kitchen in the Resident Care Center there was a clear plastic container with a red lid. The container contained 2 cups of granola with a use by date of 4/28. The Assistant Director/Dietary Manager (DM) stated, I think they forgot to change the label on that. 2. On 05/22/23 at 11:12 AM, in the main Kitchen's walk-in refrigerator there was a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to include the ongoing monitoring of bed siderails as part of their routine maintenance program for 40 beds observed during initial screening of residents and as documented on a list provided by the Administrator on 05/25/23 at 7:45 AM. The finding are: 1. During the initial tour on 05/24/23 at 10:49 AM, Resident Rooms 103, 204, 207, 312, 406 and 407 had quarter siderails in use on both sides of the bed. Observations conducted throughout the remainder of the survey revealed the side rails remained in use for all 40 residents. 2. On 05/24/23 at 1:10 PM, the Administrator confirmed the residents' bed siderails were not inspected or monitored as part of the facility's weekly or monthly routine maintenance program. The Administrator explained siderails are on the bed frames and were monitored as needed. The Administrator added they relied on staff to notify them when there was an issue that needed to be addressed with a bed siderail. 3. On 05/24/23 at 1:12 PM, the Director of Nursing (DON) stated the bed siderails were used on all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, the facility failed to ensure an Individualized Plan of Care was implemented on the use of side rails and the potential for entrapment for 1 (Resident #7) of 37 (Residents #1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #25, #26, #27, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43 and #96) sampled residents who had a diagnosis of Dementia and side rails on their beds as documented on a list provided by Administrator on 05/27/23 at 7:45 AM and failed to ensure an Individualized Plan of Care was implemented for 2 (Residents #13 and #40) of 4 (Residents #13, #38, #40 and #43) sampled residents who were at risk for wandering as documented on a list provided by Administrator on 05/27/23 at 7:45 AM. The findings are: 1. Resident #7 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behaviors and Aphasia following a Cerebral Infarction. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/23 documented the resident scored 9 (8-12 indicates moderately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a resident was adequately assessed for possible entrapment risk prior to utilization of bed rails, to prevent potential accident or injury for 1 (Resident #7) of 37 (Residents #1, #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #25, #26, #27, #29, #30, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43 and #96) who used side rails as documented on a list provided by Administrator on 05/27/23 at 7:45 AM. The findings are: 1. Resident #7 had diagnoses of Unspecified Dementia, Unspecified Severity, without Behaviors and Aphasia following a Cerebral Infarction. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of two plus persons for bed mobility and did not use bed rails. a. A Care Plan with a start date of 10/27/22 documented, .May use top two rails in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure resident medication orders and pharmacist reviews and recommendations were reviewed and signed timely by the Physician for 5 (Resident #1, #12, #17, #21 and #35) of 5 sampled residents for unnecessary medication review. This failed practice had the potential to affect 40 residents who received medications administered by the facility as documented on a list provided by the Administrator on 05/25/23 at 1:06 PM. The findings are: 1. On 05/22/23 at 12:27 PM and on 05/23/23 at 9:07 AM, during conversations with Resident #12 the Surveyor observed uncontrolled mouth movements. 2. On 05/23/23 at 3:25 PM, the Surveyor requested the monthly Medication Regimen Review (MRR) for the past 12 months for Resident #1, Resident #12, Resident #17, Resident #21, and Resident #35 from the MDS Coordinator. 3. On 05/23/23 at 3:43 PM, the DON stated, I know we are months behind on those [MRRs]. 4. On 05/23/23 at 4:16 PM, the Surveyor was unable to locate Resident #17 and Resident #35's MMR for unnecessary medications for the past 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.