Butterfield Trail Village

In the surveyor’s words

From the most serious findings on record at Butterfield Trail Village, in the surveyor’s own words.

• Actual harm, patternF726Mar 6, 2025

  Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to identify, assess, and evaluate the nursing staff's knowledge, skill level, and ability to provide emergent care in life threating situations or maintain and utilize available emergency medical equipment when reviewed for competently skilled nursing services. The findings include: A review of the facility's Facility Assessment updated [DATE] and last reviewed with the QAA (Quality Assessment & Assurance)/QAPI (Quality Assurance & Performance Improvement) committee [DATE], revealed, the persons identified in completing the assessment were the Senior Director of Healthcare Services, the Administrator, the Director of Nursing, and the Medical… […]

• Actual harm, isolatedF760Nov 20, 2024

  Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to a resident was free from a significant medication error for 1 (Resident #1) of 3 residents reviewed for medication administration. Findings include: A review of a facility policy titled, Documentation of Medication Administration, revised in April 2007, indicated, all medications administered to a resident should be documented on the resident's Medication Administration Record (MAR) immediately after (never before) it is given with the signature and title of the person administering the medication. […]

• Actual harm, isolatedF689May 26, 2023

  Based on interview, and record review, the facility failed to identify the risk of side rail entrapment which resulted in actual harm 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 side rails on their bed as documented on a list provided by Administrator on 05/27/23 at 7:45 AM, and failed to identify risk and respond to multiple elopements 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. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2023

  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 [DATE] at 7:45 AM. The findings are: 1.On [DATE] 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. […]

• No harm, potential for more than minimal, widespreadF909May 26, 2023

  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. […]