Inspection Reports for
Medicalodges Butler
103 EAST NURSERY, BUTLER, MO, 64730-2331
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
14.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
156% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
65% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted due to a medication error complaint involving the administration of incorrect insulin to a resident.
Complaint Details
The complaint involved a medication error where a resident was given 10 units of Humalog instead of 10 units of Lantus insulin on 3/7/25. The error was discovered by the administering nurse who immediately took corrective action and notified the Nurse Practitioner. The resident was treated with glucose tablets, milk, and cookies, and blood sugar levels were monitored until normalized. Staff education and disciplinary action were taken.
Findings
The facility failed to administer the correct insulin to a resident, resulting in a medication error where Humalog was given instead of Lantus. The error was identified promptly, the resident was treated and monitored, and staff education was provided.
Deficiencies (1)
F0760: The facility failed to ensure residents were free from significant medication errors by administering the wrong insulin to a resident. The medication error was corrected promptly with appropriate treatment and monitoring.
Report Facts
Residents present: 68
Insulin dose: 10
Blood sugar readings: 34
Blood sugar readings: 65
Blood sugar readings: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered wrong insulin and reported the medication error |
| NP | Nurse Practitioner | Provided orders to treat resident after medication error |
| DON | Director of Nursing | Educated LPN A and staff on medication administration after error |
| Administrator | Facility Administrator | Notified of medication error and staff education |
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Medicalodges Butler following a medication error incident involving insulin administration.
Findings
The facility failed to administer the correct insulin to a resident, resulting in a medication error. The Licensed Practical Nurse (LPN) administered Humalog instead of Lantus insulin, which was identified and corrected with staff education and monitoring.
Deficiencies (1)
F 760 Residents are free of significant medication errors. The facility failed to administer the correct insulin to a resident, giving Humalog instead of Lantus insulin on 3/7/25. The error was identified and corrected with staff education and monitoring.
Report Facts
Resident census: 68
Date survey completed: Jun 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication error finding and education |
| Administrator | Notified of medication error and involved in follow-up | |
| DON | Director of Nursing | Notified of medication error and involved in follow-up |
| NP | Nurse Practitioner | Provided orders following medication error |
Inspection Report
Routine
Census: 70
Deficiencies: 6
Date: Mar 29, 2024
Visit Reason
Routine inspection of Medicalodges Butler nursing home to assess compliance with regulatory standards including resident fund management, fall prevention, trauma-informed care, food safety, ventilation, and pest control.
Findings
The facility had multiple deficiencies including failure to timely submit Third Party Liability forms for deceased residents, inadequate fall care planning and supervision leading to resident falls and injuries, lack of trauma-informed care planning for a resident with PTSD, food safety issues in the kitchen, lack of negative airflow in certain utility and restroom areas, and pest control deficiencies in attic areas.
Deficiencies (6)
F 0569: The facility failed to ensure Third Party Liability forms were completed and submitted within 30 days of death for three deceased residents and failed to submit a check within 5 days of discharge for one resident, affecting four residents.
F 0689: The facility failed to update and implement fall care plans for two residents, resulting in a fall with fracture due to lack of proper knee brace use and inadequate supervision.
F 0699: The facility failed to identify, assess, and provide supportive interventions for a resident with PTSD, lacking care plan documentation of triggers and interventions.
F 0812: The facility failed to maintain kitchen cleanliness and equipment, including dust and food debris under refrigerators, dust on sprinkler heads, a cracked freezer gasket, and debris in dishwasher spray wand.
F 0923: The facility failed to ensure negative airflow in the soiled utility room and multiple resident restrooms, potentially affecting at least 20 residents.
F 0925: The facility failed to maintain attic areas free of pest entry points, debris, and evidence of pests, potentially affecting 40 residents.
Report Facts
Facility census: 70
Days late for TPL submission: 70
Resident falls: 4
Crack size: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding TPL form submissions and resident fund disbursements | |
| Certified Nurses Aide (CNA) B | Witnessed resident fall and described transfer procedures | |
| Certified Medication Technician (CMT) B | Described resident transfer procedures and fall circumstances | |
| Administrator | Provided information on care plan expectations and ventilation system | |
| Director of Nursing (DON) | Discussed care plan responsibilities and fall interventions | |
| MDS Coordinator | Responsible for care plan development and acknowledged missing PTSD care plan details | |
| Dietary Manager | Interviewed about kitchen cleanliness and equipment maintenance | |
| Maintenance Director | Interviewed about ventilation and pest control issues |
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 9
Date: Mar 29, 2024
Visit Reason
The inspection was conducted to identify deficiencies related to compliance with federal and state regulations at Medicalodges Butler nursing facility.
Findings
The facility was found deficient in multiple areas including notice and conveyance of personal funds, accident hazards and supervision, trauma-informed care, food safety, ventilation, and pest control. Several residents' care plans and clinical records were not adequately maintained or followed.
Deficiencies (9)
F569 Notice and Conveyance of Personal Funds: The facility failed to ensure timely completion and submission of Third Party Liability forms and checks for deceased and discharged residents. This affected four discharged residents.
A3024 Clean/Dirty Utility Areas: The facility did not provide adequately designated and ventilated utility areas for nursing supplies and equipment.
A4075 Nursing Care per Resident Condition: Residents did not consistently receive personal attention and nursing care in accordance with their condition and accepted nursing practice.
A4108 Clinical Records - assessment/interventions: Clinical records lacked sufficient information to reflect initial and ongoing assessments and interventions.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to update interventions and care plans for residents at risk of falls and did not ensure adequate supervision and assistance devices to prevent accidents.
F699 Trauma Informed Care: The facility failed to provide trauma-informed care and did not have a policy on PTSD/trauma informed care. One resident with PTSD was not properly assessed or supported.
F812 Food Procurement/Store/Prepare/Serve-Sanitary: The facility failed to maintain food safety standards including cleaning and maintenance of kitchen equipment and refrigerators, affecting all residents.
F923 Ventilation: The facility failed to ensure adequate negative airflow ventilation in utility rooms and resident restrooms, affecting at least 20 residents.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, allowing pests and debris in attic and dementia unit areas, affecting 40 residents.
Report Facts
Facility census: 70
Discharged residents affected: 4
Residents sampled: 18
Residents affected by ventilation issues: 20
Residents affected by pest control issues: 40
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Oct 24, 2022
Visit Reason
The inspection was conducted in response to a complaint regarding the presence of mice and rodent droppings in the facility.
Complaint Details
Complaint MO00208540 was investigated and substantiated based on observations of mouse droppings and resident reports of seeing mice.
Findings
The facility failed to maintain an effective pest control program, as evidenced by the presence of mouse droppings in multiple resident rooms, the Activity Director's office, the basement boiler room, and the kitchen. Open food not stored in sealed containers was also observed.
Deficiencies (3)
F925 Maintain an effective pest control program. The facility failed to ensure resident rooms and common areas were free from rodent droppings and open food was not properly sealed.
A6039 19 CSR 30-87.020(39) Inspect/Rodent Control. The facility did not minimize the presence of rodents and other insects on the premises as required.
A6040 19 CSR 30-87.020(40) Outside Openings Protected Against Rodents. Openings to the outside were not effectively protected against rodents due to missing screens and gaps.
Report Facts
Facility census: 69
Containers purchased: 40
Inspection Report
Routine
Census: 68
Capacity: 110
Deficiencies: 2
Date: Jul 1, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety, infection prevention, and control standards in the facility's kitchen and waterborne pathogen prevention program.
Findings
The facility failed to maintain cleanliness in the kitchen, including floors, utensils, and food storage; lacked operable thermometers in refrigerators/freezers; allowed food safety hazards such as damaged food and improper hair hygiene; and did not have a comprehensive waterborne pathogen prevention program meeting CMS requirements.
Deficiencies (2)
F 0812: The facility failed to keep kitchen and dry storage floors clean, maintain sanitary utensils and food preparation equipment, retain operable thermometers in refrigerators/freezers, maintain plastic cutting boards to avoid food safety hazards, follow correct hair hygiene practices, and separate damaged foodstuffs.
F 0880: The facility failed to provide and implement a comprehensive infection prevention and control program for waterborne pathogens, lacking a facility-specific risk assessment, CDC toolkit completion, water system schematic, and outbreak plan.
Report Facts
Facility census: 68
Licensed capacity: 110
Date of inspection: Jul 1, 2022
Inspection Report
Follow-Up
Census: 68
Capacity: 110
Deficiencies: 9
Date: Jul 1, 2022
Visit Reason
Follow-up inspection to verify correction of previously cited deficiencies related to food procurement, preparation, sanitation, and infection control at Medicalodges Butler.
Findings
The facility failed to maintain proper food safety and infection control standards during the initial inspection, including unsanitary kitchen conditions and inadequate infection prevention program. The follow-up inspection included review of corrective actions and plans to address these deficiencies.
Deficiencies (9)
F812 Food safety requirements were not met as the facility failed to keep kitchen and dry storage floors clean, maintain operable thermometers, sanitary utensils, and proper food handling practices.
F880 The facility failed to establish and maintain a comprehensive infection prevention and control program to prevent communicable diseases and infections.
A4013 The facility did not develop adequate operational policies and procedures to ensure residents' health and safety.
A4086 Infection control procedures were inadequate to prevent the spread of communicable diseases and timely reporting to the state.
A7003 Employees failed to maintain clean outer clothing and use effective hair restraints to prevent contamination of food or food-contact surfaces.
A7013 Food was not obtained from appropriate sources and was not free from spoilage or contamination.
A7015 Food was not protected from contamination during storage, preparation, display, or transport, risking food safety.
A7020 Refrigeration facilities lacked properly located thermometers to assure maintenance of required food temperatures.
A7046 Equipment and utensils were not constructed or maintained to be safe, cleanable, and noncontaminating to food.
Report Facts
Facility census: 68
Licensed capacity: 110
Inspection date: Jul 1, 2022
Inspection Report
Life Safety
Census: 68
Capacity: 110
Deficiencies: 19
Date: Jul 1, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with emergency preparedness and fire safety code requirements.
Findings
The facility was found not in compliance with emergency preparedness and life safety code requirements. Deficiencies included failure to maintain a comprehensive emergency preparedness program and multiple fire safety code violations related to self-closing doors, fire alarm systems, sprinkler systems, smoke barriers, evacuation plans, and fire drills.
Deficiencies (19)
E001: The facility failed to establish and maintain a comprehensive Emergency Preparedness program meeting all CMS requirements, including annual review and proper training documentation.
K223: Doors with self-closing devices failed to close or latch properly, affecting smoke zones and resident safety.
K300: Walls and ceilings failed to resist smoke passage at five locations, compromising smoke zones.
K341: Fire alarm system components were not properly installed to provide effective fire warning coverage in the kitchen.
K353: Sprinkler system maintenance and testing records were incomplete, and some sprinkler heads had excessive lint build-up or were improperly placed.
K711: Evacuation and relocation plans were incomplete or missing evacuation route maps in multiple areas.
K712: Fire drills were not thoroughly documented, lacking details on varied conditions and concurrent verifications.
K761: Maintenance and testing of fire doors were incomplete, with missing documentation and some doors not inspected annually.
K914: Electrical systems maintenance and testing records were incomplete, and some electrical outlets failed inspection.
K918: Electrical system maintenance was incomplete, including missing cover plates and delayed inspections of circuit breakers and emergency power systems.
A2008: Hazardous areas were not properly separated by fire-resistant construction and self-closing doors.
A2018: Fire alarm system requirements were not met, including incomplete installation and testing of manual pull stations and smoke detectors.
A2034: Sprinkler system testing and maintenance were incomplete and not in accordance with regulations.
A2054: Smoke section walls and doors were not properly fire-rated or self-closing as required.
A2060: Accessible evacuation diagrams were not posted on each floor in conspicuous locations.
A2063: Fire drill records were incomplete, lacking required details on time, personnel, and special problems.
A3001: The facility was not substantially constructed or maintained according to construction standards.
A3030: Electrical wiring and equipment were not properly maintained or installed per NFPA 70 standards.
A4013: Policies and procedures for resident health, safety, and rights were incomplete or not properly implemented.
Report Facts
Facility census: 68
Licensed capacity: 110
Deficiencies cited: 18
Inspection Report
Routine
Deficiencies: 0
Date: Sep 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Life Safety
Census: 66
Capacity: 110
Deficiencies: 2
Date: Nov 26, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code, specifically focusing on emergency preparedness and fire drill requirements.
Findings
The facility was found to be in compliance with emergency preparedness requirements but did not meet the applicable provisions of the 2012 Life Safety Code related to fire drills. Deficiencies were noted in the documentation and conduct of quarterly fire drills.
Deficiencies (2)
K712 Fire Drills: The facility failed to conduct quarterly fire drills at varying times on each shift with required documentation including fire size, type, alarm activation, evacuation details, and staff response. Fire drills lacked required components and documentation as specified by state regulations and NFPA standards.
A2061 Fire Drill Requirements, Evacuation: The regulation requiring a minimum of twelve fire drills annually with at least one drill involving resident evacuation was not met, as referenced by K712.
Report Facts
Facility census: 66
Licensed capacity: 110
Number of fire drills required annually: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty M. Brooks | Administrator | Signed the inspection and plan of correction documents |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 5
Date: Nov 26, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation and exploitation of resident narcotics and medication count discrepancies at Medicalodges Butler.
Complaint Details
The complaint investigation was substantiated, finding misappropriation of resident narcotics and failure to maintain accurate narcotic counts. The facility was also found deficient in notifying residents about bed hold policies and posting nurse staffing information.
Findings
The facility failed to prevent misappropriation of a resident's narcotic medication, specifically Hydrocodone, with a missing narcotic card and medication count discrepancies. The facility also failed to notify resident representatives timely about bed hold policies in some cases.
Deficiencies (5)
F602: The facility failed to prevent misappropriation of resident narcotics and maintain accurate narcotic count sheets, resulting in a missing narcotic card and discrepancies in narcotic medication counts for a resident.
F625: The facility failed to notify residents and their representatives in writing of the bed-hold policy within 24 hours of transfer to an acute care hospital for four sampled residents.
F732: The facility failed to post nurse staffing information daily in a prominent place accessible to residents and visitors, including actual hours worked and resident census.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, including misappropriation of resident property and funds.
A8006: The facility failed to provide timely informed services and charges disclosure to residents or their representatives as required.
Report Facts
Facility census: 66
Missing narcotic tablets: 30
Medication dosage: 5.325
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Involved in narcotic count discrepancies and investigation |
| LPN D | Licensed Practical Nurse | Involved in narcotic count discrepancies and investigation; reported missing narcotic card |
| Administrator | Oversaw investigation and narcotic count issues | |
| DON | Director of Nursing | Oversaw narcotic count investigation and facility compliance |
| ADON | Assistant Director of Nursing | Assisted in narcotic count investigation and staffing oversight |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Date: Nov 26, 2019
Visit Reason
Investigation of possible diversion of a resident's narcotic Hydrocodone medication after a missing narcotic card was discovered during a narcotic count.
Complaint Details
The complaint investigation was substantiated with findings that an agency LPN was responsible for the missing narcotic card of 30 Hydrocodone tablets. The nurse left the facility without authorization and did not respond to contact attempts. The facility notified the police and terminated the nurse's contract.
Findings
The facility failed to prevent misappropriation of a resident's narcotic medication when a full card of 30 Hydrocodone tablets was found missing. The investigation implicated an agency LPN who left the facility without authorization and did not respond to contact attempts. The facility notified authorities and terminated the nurse's contract.
Deficiencies (3)
F 0602: The facility failed to prevent misappropriation of a resident's narcotic medication when a full card of 30 Hydrocodone tablets was missing from the medication cart. The narcotic count was off by one card and the responsible nurse left the facility without authorization.
F 0625: The facility failed to notify the resident and resident's representative in writing of the bed hold policy within 24 hours of transfer to an acute care hospital for four sampled residents.
F 0732: The facility failed to post nurse staffing information at the beginning of each shift in a prominent place accessible to residents and visitors on the south end of the building. Staffing sheets lacked actual hours and specific unit assignments for nursing staff.
Report Facts
Residents present: 66
Missing narcotic tablets: 30
Narcotic cards counted: 34
Narcotic cards expected: 35
Residents sampled: 19
Residents with bed hold notification deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Agency Licensed Practical Nurse | Named in narcotic diversion finding; left facility without authorization; subject of investigation and contract termination |
| LPN A | Licensed Practical Nurse | Oncoming nurse who discovered narcotic count discrepancy and reported to DON |
| Administrator | Facility Administrator involved in narcotic diversion investigation and notification | |
| DON | Director of Nursing | Oversaw narcotic diversion investigation and notified authorities |
| ADON | Assistant Director of Nursing | Assisted in narcotic count and investigation |
Inspection Report
Life Safety
Census: 72
Capacity: 110
Deficiencies: 19
Date: Nov 1, 2018
Visit Reason
Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including means of egress obstructions, emergency lighting deficiencies, fire barriers, sprinkler system issues, fire alarm testing and maintenance, and smoking regulations. Plans of correction were submitted to address these deficiencies.
Deficiencies (19)
K211 Means of Egress - The facility failed to maintain unobstructed egress access in the basement, with wheelchairs, tables, and other items blocking exit corridors.
K222 Egress Doors - The facility lacked proper signage, unlocking keypad devices, and operational egress door codes in multiple locations, affecting approximately 67 residents.
K291 Emergency Lighting - Emergency lighting did not illuminate sufficiently in two basement locations, potentially hampering evacuation efforts.
K293 Exit Signage - Five directional exit signs were dimly illuminated or non-functional, affecting approximately 67 residents.
K321 Hazardous Areas - The facility failed to maintain fire resistive qualities of the furnace room wall, compromising smoke compartment integrity.
K345 Fire Alarm System - The facility failed to provide complete documentation of annual fire alarm inspections and testing.
K351 Sprinkler System - Sprinkler heads were obstructed or improperly secured, and maintenance inspections were incomplete.
K353 Sprinkler System - Maintenance and testing records were incomplete, and spray patterns of sprinkler heads were blocked in resident rooms.
K363 Corridor Doors - The facility failed to provide doors that tightly latch and close to resist smoke passage in multiple resident rooms.
K374 Smoke Barrier Doors - Two smoke barrier doors lacked self-closing mechanisms and fire resistive ratings, risking smoke containment.
K712 Fire Drills - The facility failed to conduct quarterly fire drills with required documentation for all shifts.
K741 Smoking Regulations - The facility failed to monitor and properly dispose of cigarette butts in designated smoking areas.
K761 Maintenance, Inspection & Testing - Doors - The facility failed to conduct visual, functional, and technical assessments of smoke barrier doors.
K914 Electrical Systems - Maintenance and testing of electrical receptacles were incomplete, risking electrical hazards.
K918 Electrical Systems - The facility failed to annually inspect main and circuit breaker panels and maintain documentation.
K919 Electrical Equipment - The facility failed to preserve electrical plate covers and maintain electrical system integrity in multiple locations.
K920 Electrical Equipment - Power Cords and Extension Cords - The facility allowed misuse of power strips and unsecured extension cords in resident rooms.
E004 Emergency Preparedness - The facility failed to develop and maintain an annual emergency preparedness plan with required documentation.
E039 Emergency Preparedness Testing - The facility failed to conduct required emergency preparedness exercises and maintain documentation.
Report Facts
Facility census: 72
Licensed capacity: 110
Consecutive months for compliance monitoring: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding egress obstructions, emergency lighting, fire alarm system, sprinkler system, and other deficiencies | |
| Facility Administrator | Responsible for compliance and emergency preparedness plan | |
| Maintenance Supervisor | Responsible for completing inspections and reporting to QA committee |
Inspection Report
Plan of Correction
Census: 72
Deficiencies: 4
Date: Nov 1, 2018
Visit Reason
The inspection was conducted to assess compliance with federal Medicare/Medicaid requirements, focusing on accident hazards, supervision, and medication storage.
Findings
The facility failed to ensure residents were free from accident hazards related to mechanical lift transfers and failed to properly label and store drugs and biologicals in medication rooms. Deficiencies were identified in supervision during transfers and medication storage practices.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to reduce the risk of accidents by not correctly using a mechanical lift to transfer three sampled residents. The facility census was 72 residents.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure personal belongings were not stored with medications and that medication rooms were clean and properly maintained. The facility census was 72 residents.
A4063 Medication Storage: The facility did not store medications at appropriate temperatures in a safe, clean, and orderly manner apart from foodstuffs and dangerous chemicals. This regulation was not met as evidenced by Class III deficiency.
A4074 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions, evidenced by Class II deficiency.
Report Facts
Facility census: 72
Sampled residents with transfer issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding mechanical lift training and procedures |
| Certified Nursing Assistant A | Certified Nursing Assistant | Observed transferring resident without locking wheelchair wheels |
| Certified Nursing Assistant D | Certified Nursing Assistant | Observed transferring resident without locking wheelchair wheels |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding medication storage and labeling |
| Director of Nursing | Director of Nursing | Interviewed regarding mechanical lift procedures and medication storage |
Inspection Report
Annual Inspection
Census: 74
Capacity: 110
Deficiencies: 5
Date: Jan 19, 2018
Visit Reason
The inspection was the annual survey of Medicalodges Butler to assess compliance with federal Medicare/Medicaid requirements and state regulations.
Findings
The facility was found to have medication administration errors exceeding the allowed 5% error rate and failed to ensure residents were free of significant medication errors. Additionally, the facility failed to maintain proper food temperature controls, infection prevention and control standards, and an effective pest control program.
Deficiencies (5)
F759 Medication error rate exceeded 5%, with 5 errors observed out of 27 opportunities affecting sampled residents. The facility failed to ensure proper administration of inhalers and insulin per policy.
F760 Residents were not free of significant medication errors during insulin administration, with errors observed in technique and dosage. The facility failed to ensure proper insulin pen use and medication administration.
F800 The facility failed to maintain food at safe temperatures on the steam table, potentially affecting all residents who ate food from the kitchen. Observations showed food temperatures were not taken or recorded properly.
F880 The infection prevention and control program was deficient, failing to ensure proper isolation, hand hygiene, and linen handling. The facility did not follow CDC guidelines for residents with Clostridium difficile infection.
F925 The facility failed to maintain an effective pest control program, allowing bird nests and mouse droppings in attic and special care unit areas. This potentially affected 28 residents in those areas.
Report Facts
Medication error rate: 18.52
Facility census: 74
Licensed capacity: 110
Residents affected by pest control deficiency: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Misty M. Brooks | Administrator | Signed the Statement of Deficiencies and Plan of Correction. |
| LPN C | Named in findings related to insulin administration errors. | |
| Certified Medication Technician (CMT) A | Observed administering medications incorrectly. | |
| Director of Nursing (DON) | Interviewed regarding medication administration expectations. | |
| Registered Nurse (RN) A | Interviewed about insulin pen cleaning and priming. |
Inspection Report
Life Safety
Census: 74
Capacity: 110
Deficiencies: 11
Date: Jan 19, 2018
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements, including emergency preparedness and fire safety standards, at Medicalodges Butler.
Findings
The facility was found deficient in multiple areas including emergency preparedness planning related to railroad hazards, backup communication systems, fire safety measures such as fire ratings on smoke barrier doors, means of egress, hazardous areas, electrical system maintenance, and fire protection equipment. The facility census was 74 residents with a licensed capacity of 110 beds.
Deficiencies (11)
E004: The facility failed to include the presence of a railroad track in its disaster preparedness plan, potentially affecting all residents.
E020: The facility lacked a backup phone communication system in its disaster preparedness plan, potentially affecting all residents.
K211: The facility failed to ensure visible fire ratings on seven pairs of smoke barrier doors and doors to the basement, potentially affecting all residents in 10 smoke zones.
K271: The facility failed to maintain outdoor walkways free of obstructions that could hamper evacuation, affecting at least 28 residents in two smoke zones.
K321: The facility failed to ensure visible fire ratings on doors to hazardous areas and failed to ensure combustibles were stored properly, potentially affecting at least 30 residents in three smoke zones.
K322: The facility failed to ensure combustible hand sanitizer and aerosol cans were stored in approved cabinets, potentially affecting numerous residents, visitors, and staff in one smoke zone.
K324: The facility failed to ensure cooking equipment, specifically a deep fryer, was protected according to NFPA standards, creating a fire hazard for all residents and staff in one smoke zone.
K771: The facility failed to ensure the four-year testing of pneumatic smoke dampers was conducted, potentially affecting at least 39 residents in four smoke zones.
K914: The facility failed to maintain electrical receptacles and wiring, creating electrical injury and fire hazards affecting all occupants in 10 smoke zones.
K918: The facility failed to maintain and test electrical systems and circuit breakers annually, potentially affecting all occupants in 10 smoke zones.
K921: The facility failed to ensure surge protectors were tested and maintained, creating electrical hazards affecting all residents in 10 smoke zones.
Report Facts
Facility census: 74
Licensed capacity: 110
Number of smoke zones: 11
Residents affected by K271 deficiency: 28
Residents affected by K321 deficiency: 30
Residents affected by K771 deficiency: 39
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