Inspection Reports for
Butterfield Trail Village

The complaint investigation focused on the misappropriation of Resident #1's sealed opioid medication, which was found opened and partially used without authorization. The facility conducted drug testing of nurses with negative results but could not identify the responsible party. Additionally, the investigation included a review of nursing staff competency after Resident #4 experienced a respiratory emergency and subsequent death, revealing inadequate emergency preparedness and training.

The facility failed to maintain the integrity and secure storage of a sealed opioid medication for Resident #1, with evidence of medication missing and no documented administration. Additionally, the facility failed to adequately assess and ensure nursing staff competency in providing emergent care and utilizing emergency medical equipment during a respiratory emergency involving Resident #4, including lack of CPR certification tracking, missing emergency equipment, and no mock code training.

The investigation was complaint-driven, focusing on medication administration errors and pharmaceutical service issues. Substantiation status is not explicitly stated.

The facility failed to dispense pharmacy bubble packaged pain medication according to professional standards for one resident and failed to ensure a resident was free from significant medication errors, including missed doses and improper documentation.

The complaint investigation substantiated failures related to dignity in care, lack of discharge summary, improper oxygen administration, and infection control breaches.

The facility was found to have failed in maintaining resident dignity during wound care and insulin injections by performing treatments in public areas without privacy. The facility also failed to provide a discharge summary for a resident, administered oxygen without physician orders, and did not maintain proper infection control during wound care, including failure to clean surfaces and protect wounds from contamination.

The facility was found deficient in multiple areas including failure to implement individualized care plans addressing side rail use and wandering risks, inadequate monitoring and documentation of medication regimen reviews, poor food storage and sanitation practices, and lack of routine maintenance and inspection of bed siderails.

The facility was found deficient in maintaining resident dignity due to lack of shower curtains, failure to implement individualized care plans for residents with dementia and wandering risks, inadequate supervision and risk identification related to side rail entrapment and elopement incidents, untimely medication regimen reviews and physician sign-offs, and lack of routine maintenance and monitoring of bed siderails.

The complaint investigation was triggered by reports of staff neglecting Resident #4, including ignoring call lights and not providing care. The investigation found substantiated neglect and failure to report abuse immediately as required by facility policy.

The facility failed to ensure staff reported allegations of verbal abuse in a timely manner, resulting in delayed investigations and lack of immediate protective measures. Observations and interviews confirmed neglectful behaviors by staff, including ignoring call lights and not assisting residents, affecting at least one resident directly and potentially impacting 40 residents overall.

The complaint investigation was triggered by reports of staff neglecting Resident #4 and other residents, including ignoring call lights and failing to assist residents. The investigation found substantiated neglect with some staff disciplined and an RN quitting. Reporting procedures were not followed timely.

The facility failed to ensure staff reported allegations of verbal abuse in a timely manner, resulting in delayed investigations and lack of immediate protective measures. Staff were observed neglecting Resident #4 by ignoring call lights and failing to provide care, with some staff disciplined but no formal report made initially.

The facility failed to ensure that visitation restrictions were not improperly implemented during a COVID-19 outbreak, restricting visitors for about two weeks. The facility allowed compassion visits for COVID-positive residents but initially did not allow visitors for all residents, contrary to updated CMS visitation guidelines.