Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
privacy and dignity of two sampled residents (Resident #10 and #901) out of 16 sampled
residents was maintained during cares. The facility census was 42 residents.
1. Record review of Resident#10’s Face Sheet showed he/she was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 6/26/18, showed
he/she:
-Had cognitive loss with short and long term memory dysfunction;
-Needed total assistance with bathing, dressing, toileting, transferring and mobility and
-Had limited range of motion in his/her upper and lower extremities.
Observation on 9/11/18 at 12:05 P.M., showed the resident lying in his/her bed, which was
low to the ground. The resident’s roommate was also in the room in his/her bed. The
privacy curtain between the residents was not pulled to prevent the residents from seeing
each other. Resident #10 began calling out. Certified Nursing Assistant (CNA) C
immediately responded, knocked on the door and the resident asked if it was time for
lunch. CNA C said yes and told the resident that they were going to get him/her up. The
following occurred:
-CNA D entered the resident’s room and without washing his/her hands, gloved and went over
to the roommate and began assisting him/her in his/her bed. The resident’s linen was
pulled down, exposing the resident’s brief.;
-CNA C, without washing his/her hands, put on gloves, removed the floor mat beside
Resident #10’s bed and put the resident’s bed up. CNA C then said he/she was going to
check the resident for continence and provide incontinence care;
-Without pulling the privacy curtain, de-gloving, washing or sanitizing his/her hands, CNA
C removed the resident’s brief and began performing incontinence care on the resident.;
-CNA D (when he/she was finished assisting the resident’s roommate, washed his/her hands
and gloved, then came over to assist CNA C with rolling the resident to the side to
complete the resident’s care. CNA D then pulled the privacy curtain so that Resident #10
did not continue to be exposed to his/her roommate and
-CNA C and CNA D completed the resident’s care and transferred him/her to his/her
specialized wheelchair.
2. Record review of Resident #901’s face sheet showed he/she was admitted on [DATE], and
had the following Diagnosis: [REDACTED].
-[MEDICAL CONDITION] (an overwhelming feeling of sadness that interferes in the day to day
activities of life);
-Amputation of left leg below the knee;
-Diverting [MEDICAL CONDITION]- (a surgical opening from the large intestine to the
surface of the body where feces moves into a [MEDICAL CONDITION] bag);
-Neuromuscular dysfunction of the bladder (a dysfunction of the urinary bladder due to
disease of the central nervous system or peripheral nerves involved in there control) and
-Dementia (loss of memory and other mental abilities severe enough to interfere with daily
life. It is caused by physical changes in the brain).
Record review of the residents quarterly MDS dated [DATE] showed:
-The resident was moderately to severely cognitively impaired and
-Had a indwelling suprapubic urinary catheter placed (a surgically created connection

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
between the bladder and the skin used to drain urine from the bladder in individuals with
obstruction of normal urinary flow).
Record review of the resident’s suprapubic urinary catheter care plan dated 9/10/18
showed:
-The resident’s urinary drainage bag was to be emptied every shift and as needed and
-The privacy bag for the urinary drainage bag was to be provided and used.
Observation on 9/11/18 at 9:48 A.M. and at 10:34 A.M. showed:
-The resident lying in his/her bed in his/her room, with the door open and
-His/her urinary drainage bag was not in its privacy cover, and was visible from the
hallway.
Observation on 9/12/18 at 1:16 P.M. showed the resident’s room door open, with the
resident in bed:
-The resident had his/her blanket pulled up with his her [MEDICAL CONDITION] bag showing
and
-His/her her urinary drainage bag was not in a privacy cover which was visible from the
hallway.
Observation on 9/13/18 at 10:53 A.M. showed the resident in bed:
-The resident’s had his/her blanket partially covering him/herself and the [MEDICAL
CONDITION] bag was showing and
-His/her urinary drainage bag was not in privacy cover which was visible from the hallway.

3. During an interview on 9/11/18 at 1:45 P.M., CNA C and CNA D said that when they went
into the resident’s room they should have pulled the privacy curtain.
During a interview on 9/13/18 at 12:47 P.M., CNA F said urinary drainage bags should be
kept in privacy covers.
During an interview on 9/13/18 at 12:55 P.M., CNA A said:
-Care should be taken to give a resident privacy and dignity;
-The resident should not be exposed and
– When a resident has a urinary drainage bag staff should put it in a privacy cover.
During an interview on 9/14/18 at 10:00 A.M. Registered Nurse (RN) B said:
-When cares have been done with Urinary drainage bags the drainage bags should be put in a
privacy cover;
-Staff who see urinary drainage bags not in privacy covers should put them in one as
needed and
-When has resident uncovered themselves staff needs to cover them, or asked them to cover
themselves to maintain his/her dignity.
During a follow up interview on 9/14/18 at 2:37 P.M., RN B said the nursing staff should
shut the door and pulled the privacy curtain before beginning care for any resident.
During an interview on 9/14/18 at 3:10 P.M., the Director of Nursing (DON) said:
-Upon entering a resident’s room, nursing staff should close the door and pull the privacy
curtain before starting care;
-Especially if the resident’s roommate is in the room, in order to maintain each
resident’s privacy and dignity;
-Staff were that Urinary drainage bags would be kept in privacy bags and
-If staff noticed a resident uncovered or exposed that staff would ensure the resident was
covered to preserve dignity.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to manage his or her financial affairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide a written statement
of the status of the resident’s personal funds in a clear, understandable manner at least
quarterly for one sampled resident (Resident #22) out of 16 sampled residents. The
facility census was 42 residents.
1. Record review of Resident #22’s Admission record showed he/she was admitted on [DATE],
with the following Diagnoses: [REDACTED].
-Hypertension (High blood pressure);
-[MEDICAL CONDITION] (a chronic progressive condition that affects the pumping power of
your heart muscles) and
-Depression (a persistent feeling of sadness and loss of interest in life and activities).
During an interview on 9/12/18 at 1:30 P.M., the resident requested during a resident
council meeting to speak to someone privately about a personal issue.
During an interview on 9/12/18 at 8:02 P.M., the resident said:
-He/she felt the facility had been keeping all their money and
-He/she had not received a written statement about his/her personal funds.
During an interview on 9/13/18 at 10:41 A.M., the Business Office Manager said:
-The residents have not been given monthly or quarterly statements of personal funds up to
that time;
-The resident was on Medicaid and only had the personal funds of fifty dollars a month and
-He/she needed to check when his/her Medicaid payments had started.
During an interview on 9/13/18 at 1:28 P.M., the Business Office Manager said:
-The resident’s Medicaid payments started on 8/17/17;
-The facility had no charges or administration fee’s for maintaining resident fund
accounts;
-The facility received the resident’s Social Security monies;
-The resident should have received a personal allowance of fifty dollars a month and
-He/she had not given the resident a receipt or statement about their personal funds.
During a phone interview on 9/24/18 at 10:20 A.M., the Administrator said:
-The process should have been for personal funds statements to be given at least quarterly
to the resident as required by Centers for Medicare/Medicaid;
-He/she expects the residents to receive monies per the Medicare/Medicaid policies and
-He/she expects the staff to follow the Medicare/Medicaid polices regarding personal
funds, receipts, and statements of the personal fund accounts which need to be given to
residents.

F 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Properly hold, secure, and manage each resident’s personal money which is deposited
with the nursing home.

Based on record review and interview, the facility failed to obtain the correct resident,
designee, Power of Attorney (POA), or guardian signature on their Resident Trust Fund
(RTF) account authorization for two sampled residents (Resident#10 and Resident #1002).
This deficiency potentially affected any residents with monies held in the RTF account.
The facility census was 42 residents.
1. Record review of the business office paperwork on 9/12/18 between 9:59 A.M. and 10:45

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
A.M., showed:
-Resident # 10 and Resident #1002 had their previous POA’s signatures on the facility’s
Authorization and Agreement to Handle Resident Funds and
– Resident # 10 and Resident # 1002 had Letters of Guardianship of an Incapacitated Person
and Conservatorship of a Disabled Person in their files stating that they had been
subsequently placed under the care and custody of a Public Administrator’s office.
During interview on 9/12/18 between 9:59 A.M. and 10:45 A.M., the Business Office Manager
said that in preparing for the survey audit he/she had noticed the discrepancy and left a
message the night before for the county’s Public Administrator to sign new authorizations
to correct the error.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview, the facility failed to maintain a shower chair in the
300 Hall in an easily cleanable condition, and to maintain fans for three (Resident’s #30,
#32, and #36) out of 16 sampled residents, without a buildup of dust. The facility’s
census was 42 residents.
1. Observation with the Maintenance Director on 9/12/18 at 2:20 P.M., showed a shower
chair with a nine inch (in.) tear in the 300 Hall shower room.
2. Observations with the Maintenance Director on 9/12/18, showed the following:
– At 2:14 P.M., a buildup of dust was present on the personal fan in Resident #36’s room;
– At 2:15 P.M., Resident #36 said he/she did not know how often his/her fan was cleaned;
– At 3:28 P.M., a buildup of dust was present on the personal fan in Resident #32’s room;
– At 3:51 P.M., a buildup of dust was present on the personal fan in Resident
#30’s room and
– At 3:52 P.M., Resident #30 said the fans got dirty real fast because some of the dust
came in from the hallway.
During an interview on 9/12/18 at 2:23 P.M., CNA A said the shower chair has been like
that for about five months.
During an interview on 9/13/18 at 10:09 A.M., the Central Supply Coordinator said the
following:
– He/she did not know anything about that shower chair;
– He/she had to get permission from the administrator and the corporate person to order a
new shower chair and
– Since he/she did not know about that he/she could not take the necessary steps to order
a replacement shower chair.
During an interview on 9/13/18 at 10:31 A.M., the Housekeeping Supervisor said the
housekeepers should look at the fans in the resident rooms least weekly.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
activities were provided that met individual interests and abilities for two sampled
residents (Resident #2 and #10) who were totally dependent on facility staff for care and
mobility and that residents were provided activities throughout the day and evening, out
of 16 sampled residents. The facility census was 42 residents.
Record review of the facility’s Activity Calendar dated (MONTH) (YEAR) showed the
following week of activities:
-On 9/9/18, the activities were church at 9:00 A.M., and how it’s made (television show)
at 2:00 P.M;
-On 9/10/18, showed the activities were church at 10:00 A.M., exercise at 11:00 A.M., and
bingo at 2:00 P.M;
-On 9/11/18, the activities were coffee time at 10:00 A.M., exercise at 11:30 A.M., and
music (entertainment) at 2:00 P.M;
-On 9/12/18, the activities were music at 10:30 A.M., exercise at 11:30 A.M., and ice
cream at 2:00 P.M;
-On 9/13/18, the activities were ladies nail care at 9:30 A.M., exercise at 11:30 A.M.,
and card game at 2:00 P.M;
-On 9/14/18, the activities were coffee at 10:00 A.M., exercise at 11:30 A.M., and room
visits at 2:00 P.M. and
-On 9/15/18, the activities were snack at 10:00 A.M. and snack at 2:00 P.M.
1. Record review of Resident #2’s Face Sheet showed he/she was admitted to the facility on
[DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s Annual Minimum Data Set (MDS- a federally mandated
assessment tool to be completed by facility staff for care planning) dated 6/13/18, showed
he/she:
-Was cognitively impaired, with disorganized thought , inattention and altered
consciousness;
-Needed extensive assistance with bathing, dressing, toileting, eating, mobility and
ambulation;
-Was not able to answer questions related to activity preferences or likes and
-The MDS did not show staff assessment of the resident’s activity preferences.
Record review of the resident’s Activity assessment dated [DATE], showed he/she:
-Liked music and spiritual activities, and would need to sit close to the activity so
he/she may enjoy it and
-Would need assistance to and from the activity.
Record review of the resident’s Care Plan dated 8/29/18, showed he/she had a communication
deficit related to impaired hearing and impaired cognitive ability due to dementia. It
showed the resident had little to no activity involvement related to his/her wishes not to
participate. It showed the resident’s preferred activities were family visits and people
watching. The activity goal was for the resident to express satisfaction with the type of
activities and level of activity involvement when asked. There were no interventions
showing how the facility was going to assist the resident in meeting the goal and the
frequency that activities would be offered to the resident. There were no activity
interventions documented. The goal was not measurable.
Record review of the resident’s Activity Monthly Participation Record showed the form used
to document the resident’s daily activities during the month, and showed 41 different
activities that the resident could have participated in. Activities listed on the form
were grouped according to type of activity (group activity, dementia activity, room visit
activity, cart activity and independent activity.) The resident’s activity record showed:
-August (YEAR)-the resident participated independently in the hair salon on 8/10/18, and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
in a special event/party on 8/15/18 and
-September (YEAR)- the resident independently participated in pet visits on 9/4/18,
9/6/18, 9/9/18, and 9/12/18; and participated in a group live entertainment activity, on
9/11/18.
Observation on 9/11/18 at 10:00 A.M., showed the resident sitting in his/her specialized
wheelchair by the aviary which was across from the nursing station. He/she was not
actively watching the birds in the aviary. There was a coffee time activity in the dining
room at this time.
Observation on 9/11/18 at 2:03 P.M., showed the resident asleep in his/her bed, resting
comfortably. At this time there was a music/religious activity in the main dining room.
Nursing staff did not waken the resident to take him/her to the activity.
Observation on 9/12/18 at 7:48 A.M., showed the resident sitting in his/her specialized
wheelchair in the dining room being fed by nursing staff. After breakfast, nursing staff
took the resident to the aviary in front of the nursing station, where the resident sat
until 11:00 A.M. There was a scheduled music activity at 10:30 A.M. and exercise scheduled
for 11:30 A.M. Staff did not take the resident to any of the activities. At 12:00 P.M.,
the resident was sitting in his/her specialized wheelchair in the hallway that lead to the
dining room.
2. Record review of Resident#10’s Face Sheet showed he/she was admitted to the facility on
[DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
-Had cognitive loss with short and long term memory dysfunction;
-Needed total assistance with bathing, dressing, toileting, transferring and mobility;
-Had limited range of motion in his/her upper and lower extremities and
-Did not show any activity preferences or likes and the staff assessment of the resident’s
likes or activity preferences was not documented. (Record review of the resident’s last
annual assessment dated ,[DATE] did not show the resident’s activity preferences or staff
assessment of activity preferences).
Record review of the resident’s Care Plan, updated on 6/26/18, showed he/she had a
cognitive deficit due to [MEDICAL CONDITION], limited physical mobility due to
contractures and neurological deficits, and needed total assistance from staff for all
care. His/her activity plan showed the resident had little to no activity involvement
related to his/her wishes not to participate. It showed the resident’s preferred
activities were listening to television and sitting up by the nursing desk. The activity
goal showed the resident will express satisfaction with the type of activity and level of
activity involvement when asked. There were no interventions showing how the facility was
going to assist the resident in achieving this goal or with what frequency activities
would be offered.
Record review of the resident’s Activity assessment dated [DATE], showed he/she liked to
sit up by the nursing station and watching television in his/her room. It showed the
activity plan goals were met and the interventions/approaches were effective in meeting
the resident’s goals. The documentation did not show the goals or identify how they were
being met. The documented activities did not address the resident’s capacity for decision
making or that were according to interests or activities the resident may have
participated in before entering the facility. It did not show the facility interviewed the
resident’s family to obtain a comprehensive history of the resident so that activities
could be individualized and focused on his/her interests and current abilities.
Record review of the resident’s Monthly Activity Participation Record showed:
-August (YEAR) the resident independently participated in television/radio on 8/1/18,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
8/3/18, 8/6/18, 8/10/18, and 8/13/18; participated independently in a special event/party
on 8/15/18; participated in a group music activity on 8/11/18 and in bingo on 8/13/18 and
-September (YEAR) showed the resident participated in room activity pet visits on 9/5/18,
9/7/18 and 9/10/18.
Observation on 9/11/18 at 10:00 A.M., showed the resident sitting in his/her specialized
wheelchair in the hallway by the nursing station. He/she was asleep. There was a coffee
time activity in the dining room at this time.
Observation on 9/11/18 at 2:03 P.M., showed the resident sitting up in his/her specialized
wheelchair in the dining room where there was a music/religious activity in the main
dining room.
Observation on 9/12/18 from 9:00 A.M. to 11:45 A.M., showed the resident sitting in the
hallway by the nursing station. The resident was not participating in the scheduled
activities or watching television (a desired activity). At 12:00 P.M., the resident was in
the hallway facing the dining room doors, waiting to be taken into the dining room for
lunch.
3. During the group interview on 9/12/18 at 11:03 A.M., residents attending said:
-Activities they were offered were bingo, card games, television, exercise and
occasionally entertainers that come in;
-There is a pianist who comes in weekly to play for them and they also have religious
service every Sunday;
-They don’t have current magazines or books to read-the magazines are very old;
-They do not go off of the property for activities;
-After dinner there are no scheduled activities after 2:00 P.M., and there are no
activities on weekends;
-They have not seen activity staff give one to one activities;
-It could be very boring in the evenings and resident’s usually watch television and
-They would like more scheduled activities in the evenings and on weekends.
4. During an interview on 9/12/18 at 7:15 P.M. Certified Nursing Assistant (CNA) B said:
-In the evening, there are no scheduled activities for the residents, but some of the
residents will go into the dining room to watch television;
-There are also games and cards they can play if they want to and
-The staff pass out snacks in the evening.
During an interview on 9/12/18 at 7:17 P.M., CNA E said:
-The activity staff was gone by dinner (at 5:00 P.M.) and they don’t have planned
activities for the residents in the evenings;
-The resident’s can watch a movie in the large dining room or they can watch television in
their rooms and
-The activity staff leave cards and games for residents to play and if the residents ask
for a game, nursing staff will give it to them.
During an interview on 9/12/18 at 7:30 P.M., the Social Service Designee said:
-He/she had not seen scheduled activities after 2:00 P.M. in the facility and
-The Activity Director left games, cards and movies for the residents after hours.
During an interview on 9/13/18 at 2:18 P.M., the Activity Director said:
-He/she completed scheduled activities until 2:00 P.M. daily. The 2:00 P.M. activity
usually lasted until 3:00 P.M., then afterward, he/she attended the team resolution
meeting at 3:00 P.M;
-The residents did not have any scheduled activities in the evening (after 2:00 P.M.);
-Activities in the evenings are up to the resident or nursing staff on duty to provide;
-He/she leaves board games and card games that are available for the residents to play and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
if there are sports games on television, he/she will turn the television on in the dining
room for those residents who want to watch;
-If the nursing staff initiates an activity with any of the residents in the evening, they
will document it on a slip of paper or tell her the next day.;
-He/she said on the weekends, housekeeping staff assist with activities;
-The residents have scheduled church activity on Sundays and a movie called ‘how is it
made’ that they watch on television;
-For those residents who need a lot of assistance or who are not cognitively intact,
he/she schedules and completes one to one visits for them;
-Resident #2 has music activities, and one to one visits. He/she said the resident had
daily room visits, but he/she did not have a set schedule for the visits;
– He/she said he/she tried to see the residents who needed more assistance or were
cognitively impaired (like resident #2 and #10) twice weekly for room visits;
-He/she did not know why he/she had not been able to get all of the activities (one to one
and room visits) done, but he/she recognizes that there were concerns with activities;
-He/she said he/she participates in meetings and care plans and does not have any
additional assistance;
-He/she was in the monthly resident counsel meetings and when he/she asks the residents if
there are any activities that they want to do, they don’t say they have any concerns or
complaints and
-He/she would start planning activities for after 2:00 P.M. and on weekends that nursing
staff can initiate, and that are requested by the residents.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary treatment and services as ordered by the resident’s physician for one day and to
provide ongoing assessment and documenting of the resident'[MEDICAL CONDITION] wound for
one sampled resident (Resident #32) out of 16 sampled residents. The facility census was
42 residents.
Record review of the facility’s Pressure injury and non-pressure injury Treatment Policy
and Procedure date revised 4/17 showed:
-Weekly wound measurement and documentation until healed;
-Weekly skin assessment;
-Registered Nurse (RN) to complete the wound assessment and measurement of the wound;
-Notifying the physician and resident’s representative of any changes;
-Wound Consult notification if applicable;
-Completing medical record documenting the following information should be record in the
resident’s medical record weekly and
–The date and time the wound care was given, the type of treatment, any improvement, or
decline in the resident’s wound condition, all assessment data (i.e , color, size, pain,
drainage, ect.) when inspecting the wound, the resident’s tolerance to the procedure and
the name and tile of the person performing the care.
1. Record review of Resident #32 Admission Face Sheet showed he/she:
-Was admitted to the facility on [DATE] and readmitted on [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-Was on Hospice Services (palliative care for chronic or terminal illness) and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s nursing progress notes dated 7/11/18 showed the resident
had a wound documented as [MEDICAL CONDITION] area to his/her right breast and the wound
area measured at 5.0 centimeter (cm) x 5.0 cm, x 1.5 cm and the tissues was raised.
Record review of the resident’s nurse’s notes dated 7/25/18 at 2:09 P.M., showed the
resident’s wound had a wound documented as [MEDICAL CONDITION] area to his/her right
breast and the wound measured 5.3 cm x 5.3 cm, x 1.5 cm and the tissue was raised.
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 8/11/18 showed
he/she:
-Was not cognitively impaired and has a BIMs (brief interview for mental status) score of
15 and was able to make own discussion and
-He/she had an open non-pressure lesion.
Record review of the resident’s physician’s orders [REDACTED].
-Nursing staff were to apply [MEDICATION NAME] 2% topically to the resident’s right breast
twice daily then cover with gauze; change dressing as needed, for wound care (order
originally date was 10/17/17) and
-No documentation to show a new order dated 8/21/18 to cleanse the resident’s right breast
area with wound cleanser, pat dry, apply [MEDICATION NAME] (antibiotic ointment) and cover
with a island dressing (an absorbent pad with a soft and [MEDICATION NAME] fixative layer
for simple and effective management of sutured/postoperative wounds).
Record review of the resident’s Progress Note Wound assessment dated [DATE] showed:
-The resident’s wound was documented as [MEDICAL CONDITION] area to his/her right breast
and his/her wishes were for no invasive treatment for [REDACTED].>-The wound measured
at 5.3 cm x 5.3 cm x 1.5 cm with raised tissue and
-The Physician ordered a treatment to cleanse the resident’s right breast with wound
cleanser, pat dry, apply bactriban to the area, and cover with adaptive cover with dry
dressing every day and as needed.
Record review of the resident’s POS and the Medication Administration Record [REDACTED]
-Nursing staff were to apply [MEDICATION NAME] 2% topically to the resident’s right breast
twice daily then cover with gauze; change dressing as needed, for wound care (order
originally date was 10/17/17);
-The resident’s MAR indicated [REDACTED]
-The resident’s MAR indicated [REDACTED]
-No documentation for the current wound care treatment was on the resident’s POS that had
been transcribed to the resident’s TAR for September, to cleanse the resident’s right
breast area with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with an
island dressing.
Observation and interview on 9/10/18 at 11:00 A.M., the resident said:
-He/she was on Hospice (end of life) services, for a history of [MEDICAL CONDITION];
-His/her right breast started bleeding recently;
-The nursing staff were to provide daily dressing changes;
-His/her right breast has been bleeding from scar tissue around the nipple area and the
nursing staff were to change his/her dressing every day;
-The last time the dressing was changed was on 9/8/18 and he/she raised his/her shirt up
and showed the dressing on his/her right breast area that was dated 9/8/18 with a 7-11
written on it;
-He/she had [MEDICAL CONDITION] in past and his/her physician was aware of the increase
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
bleeding in his/her right breast and
-The nursing staff had not changed his/her dressing on 9/9/18 or that morning (morning of
9/10/18).
Record review of the resident’s (MONTH) Treatment Administration Record (TAR) and MAR
indicated [REDACTED]
-The resident had a physician’s orders [REDACTED].
-Nursing staff were to cleanse the resident’s right breast area with wound cleanser, pat
dry, apply Bactrim, and cover with an island dressing;
-The nursing staff had initialed on 9/9/18 that the dressing had been changed but
observation of the resident’s dressing showed a date of 9/8/18 on the 7-11 shift and
-The resident said the dressing had not been changed on 9/9/18.
During an interview on 9/11/18 at 8:15 A.M., the resident said:
-The nursing staff did not come in to change the resident dressing on 9/10/18;
-He/she had been waiting and no nursing staff had come and
-He/she said the Hospice nurse was to come today, 9/11/18 and they would probably change
his/her dressing.
Observation and interview on 9/11/18 at 9:54 A.M. showed:
-The resident was accompanied by the Hospice case manager nurse and the Hospice health
aid;
-The Hospice aid said he/she left the resident’s dressing in place during the shower and
after the shower the facility staff would remove the dressing and clean the area;
-The resident’s wound dressing was dry and intact with a slight amount of dried brownish
drainage on the bottom part of the dressing and was dated 9/8/18 with a 7-11 written on it
and
-The resident said no one had changed the dressing for two or three days and it was to be
changed every day.
Observation of the resident’s wound care and dressing change on 9/11/18 at 10:15 A.M.
showed Registered Nurse (RN) A:
-Washed his/her hands when he/she entered the resident’s room, then applied gloves to
his/her hands;
-Removed old soiled dressing which had been dated 9/8/18 on 7-11 shift, that had brown red
drainage with no odor noted;
-RN A removed his/her gloves and washed his/her hands, applied new gloves and sprayed the
breast area with wound cleanser, patted the area dry;
-RN A removed his/her gloves and wash his/her hands, applied new gloves, with a q-tip
application stick applied [MEDICATION NAME] to the resident right breast area;
-The resident’s breast tissue was the size of tennis ball with two dimes sized areas to
the inner left aspect. The tissue was lumpy reddish -pink looking to the right breast,
with small amount red tinge drainage;
-RN A then applied Adaptec non-adhesive dressing (is a Non-Adhering Dressing protects the
fragile tissue in wounds by its unique structure with small mesh size, preventing tissue
adherence) and then covered with Island dressing;
–Hospice Nurse was also in the resident’s room to learn how to change the resident’s
dressing;
-RN A removed his/her gloves after care and washed his/her hands and
-The resident denied any pain with right breast area and had no redness underneath the
right breast mass tissue.
During an interview on 9/11/18 at 10:30 A.M., RN A said:
-The resident was to have the dressing changed to his/her right breast done every day;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-Review of the resident’s TAR with RN A showed that the dressing change was not done on
9/10/18 because there was no documented nursing initials on the TAR and 9/9/18 had nursing
initials but the resident’s dressing was dated 9/8/18 on the 7-11 shift;
-The order on the TAR showed the nursing staff was to change the resident’s dressing to
his/her right breast daily, cleanse with wound cleanser, pat dry, then apply [MEDICATION
NAME] to the area and cover with island dressing;
-RN A said the resident’s dressing should have been changed every day;
-The nursing staff were to document in the resident’s TAR and the resident’s nursing note
when the treatment had been done and
-The wound nurse did the weekly wound care assessment which would include any detailed
description of the resident’s wounds and measurements of the wounds.
Record review of the resident’s progress note dated 9/11/18 at 11:21 A.M., showed:
-The resident’s physician had been called and a message left that the resident’s dressing
change had not been done on 9/9/18 and 9/10/18;
-The nurse talked with the office nurse and he/she would relay the message and
-The resident’s physician would contact the facility of any treatment changes.
During an interview on 9/13/18 at 4:00 P.M. the Director of Nursing (DON) said:
-He/she would expect nursing staff to assess and document in the resident’s weekly wound
assessment record and also in his/her nursing progress notes;
-The documentation would include the resident’s wound measurements and a detailed
description of the resident’s wound and
-He/she could not find any other wound documentation measurement expect for 8/21/18.
During an interview on 9/14/18 at 3:01 P.M. the DON said:
-He/she would expect nursing staff to following the resident’s physician order
[REDACTED].>-The wound care group that was coming to the facility weekly, was having
scheduling issues had not been to the facility;
-The wound clinic staff had been doing most of the resident’s wound measurements and
documentation with a detailed description of the resident’s wound;
-The facility wound nurse would transcribe the information into the resident’s medical
record;
-The facility nursing staff would also obtain a copy of the wound clinic reports and
-Licensed Practical Nurse (LPN) Charge nurse/wound nurse had been taking an online wound
training and had just finished part of the wound course.
During an interview on 9/14/18 at 3:10 P.M., LPN A/ Wound Nurse said:
-Licensed Nursing staff should have documentation in the resident’s progress notes and on
his/her wound assessment at least weekly for his/her wounds;
-The resident’s electronic weekly wound assessment should include the measurement of the
resident’s wound and a detailed description of the resident’s wounds, to include the type
of wounds and the staging of the wounds;
-The facility had been short hand on nursing staff and he/she had not been able to
complete the resident’s weekly wound assessment, which would have included a detailed
description and measurement of the resident’s wounds;
-He/she said no other nursing staff have been trained in wound management or measuring of
the resident’s wounds and
-LPN A had checked the resident’s medical record and the last wound assessment of his/her
wounds documented by the facility nurse staff was on 8/21/18.
During an telephone interview on 9/24/18, and review of the emailed documentation from the
DON and the Administrator said:
-During their investigation and talking with the weekend nursing staff they had received a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
written statement from LPN B that showed he/she had written that the resident’s dressing
had been changed on 9/9/18;
-LPN B had accidentally put the wrong date of 9/8/18 on the dressing;
-He/she had documented the treatment on the resident’s TAR by his/her initial and
-The resident did not receive wound care treatment on 9/10/18 by nursing staff.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide ongoing
wound care assessment to include detail description and measurement of the pressure injury
wound and to update the resident comprehensive care plan to reflect the current condition
and treatment of [REDACTED].#14) out of 16 sampled residents. The facility census was 42
residents.
Record review of the National Pressure Ulcer Advisory Panel redefined the definition of a
pressure injuries during the NPUAP (YEAR) Staging Consensus Conference showed:
Pressure injury is a localized damage to the skin and underlying soft tissue usually over
a bony prominence or related to a medical or other device. the injury can present as
intact skin or an open ulcer and may be painful. the injury occurs as a result of intense
and /or prolonged pressure or pressure in combination with shearing. The tolerance of soft
tissue for pressure and shear may also be affected by nutrition, perfusion, co-morbidities
and condition of the soft tissue;
Stage 1 Pressure Injury: Non-blanchable (no change in the skin color when push on it)
[DIAGNOSES REDACTED] of intact skin. (Intact skin with non-blanchable redness of a
localized area usually over a bony prominence).
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.
Stage 3 Pressure Injury: Full-thickness skin loss.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss.
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple
discoloration.
Record review of the facility’s Pressure injury and non-pressure injury Treatment Policy
and Procedure date revised 4/17 showed:
-The nursing staff is to complete a weekly wound measurement and documentation on the
resident until the wound is healed;
-Complete Weekly skin assessment on the resident
-Registered Nurse (RN) is to complete a wound assessment and measurement of the wound;
-Nursing staff are notifying the resident’s physician and resident’s representative of any
changes and to notify the Wound Consultant, if applicable;
-Nursing staff are to document the following information in the resident’s medical record
weekly and
–The date and time the wound care was given, the type of wound treatment, any improvement
or decline in the resident’s wound condition, all assessment data (i.e , color, size,
pain, drainage, ect.) when inspecting the wound, resident’s tolerance to the procedure and
the name and title of the person performing the care.
1. Record review of Resident #14’s Admission Face Sheet showed he/she was admitted to the
facility on [DATE] and readmitted on [DATE] and 8/26/18 including the following Diagnosis:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
[REDACTED].>-Stage 4 Pressure ulcer of sacral region (lower part with the coccyx
(tailbone);
-Diabetes Mellitus type 1 (insulin-dependent);
-[MEDICAL CONDITION] (paralysis of all four limbs) and
-[MEDICAL CONDITION].
Review of the resident’s Discharge Minimum Data Set (MDS-a federally mandated assessment
instrument completed by facility staff for care planning) dated 6/10/18 showed he/she:
-Had one healed stage 3 pressure ulcer;
-MDS question to state the number of current pressures ulcer if the resident had either
pressure ulcer that was not present or was at a lesser stage prior to assessment was
showed:
-Had two Stage 4 pressure ulcers and
-Wound measurement for one of the Stage 4 wound was 9.0 centimeter (cm) x 7.0 cm x 7 cm.
Review of the resident’s skin observation tool dated 8/4/18 showed:
-The resident had three pressure wounds Stage 2 on his/her sacrum, left gluteal fold and
right gluteal fold;
-Documented on the note section said the resident came to the facility with three pressure
area in the coccyx’s area. The dressing are changed three times a day with Dakins (an
antiseptic solution developed during World War I for the treatment of [REDACTED].
-The tool did not have a detail description or measurement of the wounds.
Record review of the resident’s Quarterly MDS dated [DATE] showed he/she:
-Was alert and oriented, able to make his/her self-understood and can understand others;
-Was not cognitively impaired and had a BIMs (brief interview for mental status) score of
15 (was able to make his/her own discussion);
-Had [DIAGNOSES REDACTED].
-Had been admitted to the facility with Stage 3-4 pressure wounds;
-Wound measurement for one of the wound was 9.2 cm x 5.2 cm x 5.0;
-Wound tissue had granulation of 100% (pink or red tissue with shiny, moist granular
appearance) and
-Required total assistant of two staff members for transfer and bed mobility.
Record review of the resident’s progress notes related to wound care and wound assessment
from 7/31/18 to 8/31/18 showed the resident did not have any detail nursing documentation
of the wound care or detailed weekly wound assessments from 8/2/18 to 8/20/18.
Record review of the resident’s physician progress notes [REDACTED].M. showed the
resident:
-Had been followed by wound care for his/her wound on his/her coccyx;
-Had a low air loss mattress for pressure reduction;
-Plan was to continue with repositioning him/her while in bed or in his/her wheelchair;
-Was to be turned from side-to-side every two hours by staff;
-Had multiple trips to the hospital for his/her wound care;
-To be scheduled to see a specialty physician in the area for a possible flap closure of
his/her wound and
-Coccyx wound dressing was dry and intact during the time of his/her physical exam.
Record review of the resident’s Nutritional Progress note dated 8/14/18 at 12:04 P.M.
showed the resident:
-Eats 50% or less of meals per staff report and receives tube feeding from 8:00 P.M. to
6:00 A.M. of [MEDICATION NAME] 1.5 at 80 cubic centimeters(cc) an hour and
-Had pressure injury to his/her left and right gluteal fold and sacrum, all Stage 2
pressure wounds per nursing staff.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
Record review of the resident’s skin observation tool dated 8/16/18 showed:
-The resident had four pressure wounds. Two on his/her sacrum, left gluteal fold and right
gluteal fold, and had n/a by the staging;
-Documented on note section; the resident had four areas on his/her sacrum area and
-Did not have detail description or measurement of the wounds.
Record review of the resident’s Treatment Administration Record (TAR) for (MONTH) (YEAR)
showed:
-The resident was in the hospital on [DATE] to 8/26/18;
-The resident’s physician’s orders [REDACTED].
–Cleanse with wound cleanser, pack the wound lightly with gauze moistened with
1/4 strength dakins solution and cover with a ABD pad. Change the dressing two times a day
and
-Did not indicate the staging of the resident’s wound or the type of the wounds.
Record review the resident’s Wound Progress Notes dated 8/21/18 at 4:57 P.M., showed:
– The weekly wound assessment and measurement was completed;
-Interventions being utilized at that time included repositioning, the resident’s heels
are to be raised while in bed, pressure relieving wheelchair seat cushion, specialty
mattress, additional supplements as ordered and the resident was admitted with a Stage 2
and a Stage 3 pressure injury;
-Wound on his/her coccyx was a Stage 3 pressure injury and measured 3.0 cm x 1.4 cm x 3.0
cm;
-The wound bed had a 100% granulation (pink or red tissue with shiny, moist, granular
appearance) no odor noted to the wound;
-Wound on his/her left thigh (rear), was a Stage 3 pressure injury and measured 9.2 cm x
5.2 cm x 5.0 cm ; the wound bed with the Dakin’s soaked gauze pads. Cover the wounds with
a dry dressing;
–The resident’s dressing on his/her wounds was to be changed two times a day and
-The resident response to treatment and the wounds had improved and he/she had tolerated
the assessment and dressing change well.
Record review of the resident’s Hospital Wound Care Record dated 8/22/18 showed he/she had
been seen by the hospital wound care team while in the hospital for evaluation and
treatment on 8/22/18:
-Wound#1 on his/her coccyx, had a Stage 4 pressure injury with moderate amount of
serosanguineous drainage (is wound discharge that contains both blood and blood serum,
thin, watery, pale red to pink plasma with red blood cells) and necrotic (blacken,
unhealthy tissue) tissue;
-Risk factor was the resident had a history of [REDACTED].
-The resident a surgical debridement (procedure that removes unhealthy dying tissue, to
help promote healing of healthy tissue) on his/her wound while in the hospital;
-The resident’s coccyx wound, was cleansed with sterile saline and a 4×4 gauze pad, and
then debrided;
-The resident’s wound was re-dressed with [MEDICATION NAME] silver dressing (antimicrobial
silver dressings are intended for use over partial, full thickness and acute wounds; can
be let on for 3 days) and covered with a foam occlusive dressing (is used for wounds with
light to medium exudates);
-Wound #2 on his/her left ishium was a Stage 4, was cleansed with sterile saline and 4×4
gauze pad, then debrided and afterward the wound was re-dressed with [MEDICATION NAME]
silver dressing and covered with a foam dressing;
-Wound #3 on his/her right ishium was a Stage 2 and now healed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-Had photos taken and measurement of his/her wounds was done by clinic nursing staff and
placed in his/her clinic record. The resident’s facility medical record did not have a
copy of the resident’s wound measurement or photos of his/her wounds from the visit on
8/22/18;
-Plan of care for the resident was the wound dressing will be changed by nursing staff
prior to discharge back to the nursing home on 8/25/18 and
-Plan of care was the resident’s family would like the resident to continue coming to the
outpatient wound clinic for ongoing wound care treatment, but reported transportation
issues, will discuss treatment option.
Record review of the resident’s Wound Care Plan dated 8/22/18 showed the resident:
-Had two Stage 3 pressure ulcers, one on his/her coccyx and one on his/her right ischial
trochanter with osteo[DIAGNOSES REDACTED] ( bone infection).
-Intervention includes:
–Coccyx wound cleanse with normal saline, apply skin prep, apply Puracol AG (is infused
with silver to kill chronic infections and antibiotic-resistant bacteria that prevent the
wound from healing) then cover with xeroform dressing (is also an occlusive dressing which
means the dressing prevents air from reaching the wound) to hold in place, cover with ABD
gauze pad (Abdominal Pads, are used for large wounds or for wounds requiring high
absorbency) and secure with tape. Change the resident’s dressing daily and as needed when
soiled. (Was dated 12/26/17 and reviewed on 8/21/18);
–Required nursing staff to monitor and document the location of the resident wound, the
size of the wounds and the treatment of [REDACTED].
-Wound care plan did not have the resident’s most current up to date wound information
related to the resident’s staging of his/her wounds, or the resident’s current physician
order [REDACTED].
Record review of the resident’s Nursing progress notes and Medical Record for
documentation related to his/her readmission on 8/26/18 showed the resident did not have
comprehensive Wound Assessment and admission measurement of his/her Stage 4 wounds
completed upon his/her return from the hospital by nursing staff.
Record review of the resident’s Social Service Note dated 8/28/18 at 5:22 P.M., showed:
-The resident had returned from the hospital;
-The resident required total assistant for his/her care from the staff;
-Due to him/her being paralyzed, the resident was not able to use his/her call light;
He/she had a specialized call light system that he/she had to blow into for assistance
from staff and
-The resident was very alert and was able to let his/her needs be known.
Record review of the resident’s Comprehensive Care Path Note dated 8/28/18 at 7:30 A.M.,
showed the nursing note included the resident’s vital signs and general overall health and
did not have any documentation written in the area relate to the assessment of the
resident’s Stage 4 wounds.
Record review of the resident’s Physician order [REDACTED].
-Had a physician’s orders [REDACTED]. two times a day;
-Had a physician’s orders [REDACTED]. two times a day and
-Did not indicate the staging of the resident’s wounds or the type of the wounds.
Record review of the resident’s TAR dated (MONTH) (YEAR) showed:
-The resident was to have a Weekly Skin assessment;
-Braden scales weekly for four weeks;
-Weekly skin assessment on Thursday by the nursing staff and
-The resident’s physician’s orders [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
Record review of the resident’s TAR for (MONTH) (YEAR) that had physician’s orders
[REDACTED].
-Had wound care treatment for [REDACTED]. two times a day;
-Left buttocks was to cleanse the wound with wound cleanser, then pack the wound lightly
with gauze pad moisten with Dakin’s solution and cover with an ABD and the nursing staff
were to change the resident’s dressing two times a day and
-Did not indicate the staging of the resident’s wounds or the type of the wounds.
Record review of the resident’s nursing progress note dated 9/4/18 at 11:29 A.M., showed
the resident:
-Had a Stage 4 wound on his/her coccyx:
-Was to continue on antibiotic for his/her wounds and pneumonia;
-Wound on his/her coccyx was pink and had a large amount of serosanguineous drainage from
his/her wound;
-Was to have his/her Stage 4 wounds dressing changed two times a day and
-No documentation related to measurement of the resident’s wounds or the description of
the resident’s ishium Stage 4 wound.
Record review of the resident medical record from 8/26/18 to 9/13/18 showed the resident
did not have any documentation of a detailed weekly Wound Assessment and measurement of
the resident’s Stage 4 pressure injury’s on his/he coccyx and left ishium.
Record review of the resident’s progress notes related to wound care and wound assessment
from 9/5/18 to 9/13/18 showed the resident did not have detail nursing documentation of
his/her wound care treatment to include; The date and time the wound care was given, the
type of wound treatment, any improvement or decline in the resident’s wound condition, all
assessment data (i.e , color, size, pain, drainage, ect.) when inspecting the wound,
resident’s tolerance to the procedure.
During an interview on 9/11/18 at 10:30 A.M., Registered Nurse (RN) A said:
-The nursing staff are to document in the resident’s TAR and the resident’s nursing note
when completing wound care and
-The wound nurse does the weekly wound care assessment which would include any detail
description of the resident’s wounds and measurements of the wounds.
During an interview on 9/13/18 at 4:00 P.M. the Director of Nursing (DON) said:
-He/she would expect nursing staff to assess and document in the resident’s weekly wound
assessment record and also in his/her nursing progress notes;
-The documentation would include the resident’s wound measurements and detail description
of the resident’s wound and
-He/she could not find any other wound documentation measurement expect for 8/21/18 and
information obtain the fax documentation from the resident’s hospital stay on 8/22/18.
Observation of the resident’s wound care on 9/14/18 at 9:40 A.M., showed:
– RN B had the resident’s wound care supplies on clean barrier included; Dakin’s solution,
4×4 gauze pads, gloves, roll of tape and cover dressing;
-The resident’s soiled dressing was removed, had large amount of reddish pink drainage on
the dressing;
-The resident’s wound on left ishium was the around the size of a golf ball, with pink and
white boarder; The inner wound bed was red with slight reddish -pink drainage;
-The resident’s coccyx wound was the size of small baseball size wound, had same boarder
edges with depth to the wound; The inner wound bed was red with slight reddish -pink
drainage;
-RN B had several 4 x 4 gauze pads layered together in his/her gloved hand and poured
normal saline over them;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-He/she cleaned the resident’s left wound with normal saline soaked 4×4 gauze pads;
-Then removed the first top layer of the soiled gauze pad;
-With the same gloved hands and with the new clean layer of gauze pads, he/she wipe the
inside the resident’s wound;
-Then removed the first top layer of the soiled gauze pad;
-He/she then repeated the process for the resident’s coccyx wound;
-RN B had worn the same pair of gloves while he/she cleaned the two separate wound areas
and
-He/she moistened the 4×4 gauze pad with Dakin’s solution placed inside the left wound and
then with same gloves applied the same treatment for [REDACTED].
During an interview on 9/14/18 at 1:30 P.M., RN B said:
-During wound care for the resident; he/she place soak gauze in pile and soiled gauze on
top removed into other hand while continue to clean the wound with the new clean gauze pad
and continue the process;
-He/she should have changed his/her gloves and his/her wash hands after cleaning the wound
before applying the wound treatment;
-Documentation of the resident’s wound treatment was to be on resident’s nursing progress
notes and on the resident’s TAR/MAR;
-Documentation should include type of treatment, what the wound looked like and any
changes to the resident’s wound, and if the resident’s physician had been notified;
-The resident’s Weekly wound measurements and wound assessment of the resident’s wound are
done by the wound nurse or the the wound clinic and
-The DON and nursing staff are responsible for monitoring the resident’s medical record to
ensure to have documentation and assessment required for each resident.
During an interview on 9/14/18 at 3:01 P.M. the DON said:
-He/she would expect nursing staff to following the resident’s physician’s orders
[REDACTED].
-A wound care group had been coming to the facility weekly, but recently have been having
scheduling issues, so they have not been coming;
-The wound clinic staff had been doing most of the resident’s wound measurement and
documentation related detail description of the resident’s wounds;
-The facility wound nurse would transcribe the information into the resident’s record;
-The facility nursing staff wound also obtain a copy of the wound clinic report,
-Licensed Practical Nurse (LPN) Charge nurse/wound nurse had been taking an online wound
training just finished part of the course and
-He/she would expect the nursing staff to change their gloves and wash their hand between
a clean and dirty process.
During an interview on 9/14/18 at 3:10 P.M., LPN A/ Wound Nurse said:
-Licensed Nursing staff should had documentation in the resident’s progress notes and on
his/her wound assessment at least weekly for his/her Stage 4 wounds;
-The resident’s electronic weekly wound assessment should include the measurement of the
resident’s wound and detail description of the resident’s wounds, to include the type of
wounds and the staging of the wounds;
-The facility had been short handed on the nursing staff and he/she had not been able to
complete the resident’s weekly wound assessment, which would had included detail
description and measurement of the resident’s wounds;
-He/she said no other nursing staff have been trained in wound management or measuring of
the resident’s wounds;
-The resident was being seen for wound care treatment by the wound clinic also;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-Due to the resident’s recent decline in his/her medical condition, the wound clinic will
not see the resident until he/she is medically stable;
-LPN A had checked the resident’s medical record and the last wound assessment of his/her
wounds documented by the facility nurse staff was on 8/21/18 and the wound hospital notes
was on 8/22/18 and
-He/she had been taking online course to become a certified wound care nurse.
During a telephone interview on 9/21/18 at 12:09 P.M., Physical therapist (PT) A said:
-The resident was only seen by himself/herself while an in-patient at the hospital;
– The family would like for the resident to be able to come to hospital for outpatient
wound care, but due to his/her medical health risk factors, small space in clinic and
transportation issue, he/she felt not practical or best solution for the resident;
-Since he/she had been seeing the resident when admitted had been in the hospital, the
resident’s wound have improved overtime;
-The resident currently in the process of working with a local physician for a possible
tissue graft surgical wound treatment and afterward would need negative wound pressure
care (is called a vacuum-assisted wound closure, refers to wound dressing systems that
continuously or intermittently apply subatmospheric pressure to the surface of a wound);
-The resident had been seen by the specialty physician on 9/21/18, possible schedule for
surgery the following week;
-He/she said the concern he/she had was with confusion the facility’s staff had with the
recommended wound treatment order for the resident, and the facility staff lack of
knowledge on the assessment of the resident’s with pressure injury’s including measuring
and staging of the resident’s wounds;
-If the resident’s wound was a stage 4 at any time, it does not convert back to a Stage 2
or 3 if healing, would be documented as healed Stage 4 pressure injury and
-The resident’s wound was a Stage 4 pressure injury to his/her coccyx and a Stage 4 to
his/her left ishium, the right ishium was a Stage 2 that was almost healed,
-He/she was unsure if the resident was being seen by out-source wound clinic prior to
his/her many hospitalization .
During an telephone interview on 9/24/18 at 3:30 P.M., DON and Administrator said:
-They had not found any other detail wound assessment for the resident wounds expect for
the 8/21/18;
-The resident’s (MONTH) and (MONTH) TAR, had documentation of the resident’s wound
treatments by each dated done documented by the nursing initials;
-The resident’s right ishium wound had healed;
-The resident had not been seen at the facility by wound care provider;
-When the resident had been admitted to the hospital that was when the outside wound
specialist had seen the resident and
-Recently the resident did have a appointment with the outside wound clinic and plan for
possible surgery for [REDACTED].

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
mechanical lift (an assistive device that allows persons with limited mobility to be

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
transferred between a bed and a chair or other similar resting places, using hydraulic
power) was safe and in proper working order prior to transferring one sampled resident
(Resident #38) out of 16 sampled residents. The facility census was 42 residents.
Record review of the facility’s Transfers and Lifts policy and procedure dated (MONTH)
2014, showed the facility will ensure that all staff members are instructed in safe
transfer and lifting technique and how to report suspected injuries. It showed:
-You must have training on how to use any equipment before the first time you use it;
-Make sure all equipment or assistance is available;
-There must be two staff members for lifting non-weight bearing residents and
-Use the equipment as it is designed to be used, safely, with attention, and with good
body mechanics.
1. Record review of Resident #38’s Face Sheet showed he/she was admitted on [DATE] with
[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/5/18, showed
he/she:
-Was alert oriented and had no memory difficulties;
-Needed extensive assistance with transfers and mobility, toileting, dressing and hygiene;
-Had lower extremity impairment on one side with limited range of motion and
-Mobilized in a wheelchair.
Observation on 9/11/18 at 9:03 A.M., showed the resident was not in his/her room at this
time. The resident’s room was homelike. There was a full body mechanical lift over the
resident’s bed with wires coming from the top of the lift that were exposed. Over the
resident’s bed was a triangle for positioning assistance. The resident had a bariatric
(oversized) bed.
During an observation and interview on 9/11/18 at 10:35 A.M., showed the resident sitting
in his/her wheelchair in his/her room wearing a nasal cannula (a device used to deliver
supplemental oxygen through a plastic tube into the nose in a sanitary manner) and
watching television. He/she had ace bandage wraps on both of his/her legs from just below
the knee down to his/her feet. The resident said:
-He/She used to get up (transfer) with a sit to stand lift until a month or so ago, a
contusion, that was repaired while he/she was in the hospital, opened up and he/she needed
additional surgery on his/her right leg. He/she said he/she now needed two staff to lift
him/her with the mechanical full body lift to transfer until he/she is able to bear weight
on her leg again.
During an interview on 9/12/18 at 9:10 P.M., Certified Nursing Assistant (CNA) E said:
-The nursing staff normally used the purple mechanical lift to transfer the resident;
-The resident had a designated sling for the lift because it was bariatric. and fit the
resident;
-They used to transfer the resident using the stand up lift but now they have to use the
full body lift;
-He/she noticed that the lift was not working properly a couple weeks ago and other
nursing staff noticed it also;
-The lift would still go up and down, but it would not tilt (as it had before) when they
laid the resident down;
-They notified maintenance about it and were told, about three days ago, that it would be
repaired, but it did not seem that it had been repaired yet and
-Nursing staff still used the lift to transfer the resident.
During an observation and interview on 9/12/18 at 9:28 P.M., the Director of Nursing (DON)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
said:
-If the mechanical lift that nursing staff has been using to transfer the resident was not
working properly, they should not be using the lift and it should be out of service;
-The facility has purchased two new lifts with slings that can lift up to 450 pounds;
-The lifts are appropriate and can be used to transfer the resident;
-At this time the DON went to the resident’s room and CNA B and CNA E were in the room
with the purple mechanical lift and had just finished transferring the resident into bed
using the lift. The DON told them that the lift should not be used because it was not
working properly. The DON then instructed the CNAs to take the lift out of service and
said it would not be used until it was repaired and
-At 9:38 P.M., the DON said that the lift would not be used, he/she had put a maintenance
work order in for its repair and he/she was going to schedule an in-service with all
nursing staff about the use of that lift.
2. Observations on 9/11/18 at 8:50 A.M., 9/12/18 at 9:54 A.M., 9/12/18 at 2:27 P.M., and
on 9/12/18 at 9:24 P.M., showed mechanical lift #3 with a missing plate on top with the
wiring loose.
Observation on 9/12/18 at 9:24 A.M., showed:
– The DON knocked and entered the room, and asked the CNAs why the new mechanical lifts
weren’t used;
– The (CNAs) stated that the #3 mechanical lift was used, due to the sling that was under
the resident;
– The DON said there were two new mechanical lift is because this one should not be used
and there were slings that could be used with the new lifts and
-The CNAs were instructed to remove mechanical lift from room [ROOM NUMBER] and to put
sign on it and to move it to an empty room on 400 hall for storage.
During an interview on 9/12/18 at 2:47 P.M., CNA B said he/she noticed the exposed wiring
of the lift a few days prior to 9/12/18.
During an interview on 9/13/18 10:11 A.M., the Central Supply Coordinator said the
Administrator would order the parts for the lift and if the lift was damaged, they (CNAs)
can fill out a work order.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure safe
storage and labeling of Mantoux [MEDICATION NAME] PPD (A protein extracted from [DIAGNOSES
REDACTED] that is used in a skin test to determine if a person has been exposed to
[MEDICAL CONDITION]) vial, and controlled substance medications for one sampled (Resident
#26) out of 16 sampled residents. The facility census was 42 residents.
Review of the Center Of Disease (CDC) Mantoux [MEDICATION NAME] PPD Manual dated ,[DATE]
showed:
-The [MEDICATION NAME] PPD label should indicate the expiration date;
-If it’s been opened more than 30 days or the expiration date has passed, the vial should
be thrown away and a new vial used and
-When you open a new vial, write the date and your initials on the label to indicate when

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
the vial was opened and who opened it.
Review of the facility’s Medication Administration policy revised ,[DATE] showed:
-Medication shall be administered in a safe and timely manner and as prescribed;
-When opening a multi dose container the date shall be recorded on the container;
-Medication carts are to be kept locked and closed when out of sight of the medication
nurse or aide and
-No medications are to be kept on top of the medication cart.
1. Observation and review of the facility medication room and supply room on [DATE] at
11:16 A.M., showed:
-An open, undated vial of [MEDICATION NAME] PPD;
-Two pre-moistened active cavity dressings that expired ,[DATE];
-Three 4×8 foam dressings that expired ,[DATE];
-Ten 4×4 foam dressings that expired ,[DATE] and
-Resident #26 had a open, and undated bottle of [MEDICATION NAME] (medication used to
reduce anxiety).
2. Observation on [DATE] at 9:11 A.M., of the morning medication administration of
Registered Nurse (RN) B showed:
-He/she went into resident’s room leaving the medication cart unlocked and
-Had left a resident’s topical pain relief patch on top of the cart unsecured.
During an interview on [DATE] at 10:3O A.M., RN B said:
-He/she realized he/she had left the medication cart unlocked;
-He/she knew that he/she should have locked the cart before entering a residents room and
-He/she should not have left a topical medication patch sitting on top of the medication
administration cart unsecured and accessible to other residents and staff.
3. During an interview on [DATE] at 11:20 A.M., RN A said:
-All the nursing staff were responsible for checking for expired medical items and
medications;
-If needed the supplies staff would order an item and he/she would restock items and check
for dates and
-Medications should be dated when opened.
During an interview on [DATE] at 12:09 P.M., the Director of Nursing (DON) said:
-The nursing staff were to check for expiration dates on medications including [MEDICATION
NAME] PPD;
-He/she would expect nursing staff to date all medications when they were opened and
-He/she was not aware of any residents that had a physicians order for the dressings that
were expired.
During a follow up interview on [DATE] at 2:55 P.M., RN A said:
-He/she ensures the medication cart had been locked before entering a resident’s room;
-He/she would not leave any type of medication sitting on top of the medication cart while
in a resident room; and
-Medication when left on the Medication cart top could be taken by a resident.
During a follow up interview on [DATE] at 3:28 P.M., with the DON said:
-When nursing staff are not taking medications from the cart that the cart would be locked
and
-He/she would not expect medication to be left on top of the cart without nursing staff
present.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

Based on record review, and interviews, the facility failed to educate all staff as to the
existence, whereabouts, and content of a written, on-site policy regarding the acceptance,
usage, and storage of foods brought into the facility for residents by family and other
visitors, to ensure the food’s safe and sanitary handling and consumption. This deficient
practice had the potential to affect all residents who ate food brought in by visitors.
The facility census was 42 residents.
1. Record review on 9/11/18 at 12:15 A.M., of the policy entitled Food from Outside
(Brought by Families) provided by the Regional Nurse showed a generic document obtained
online that had the corporate logo added to the upper right corner.
During an interview on 9/11/18 at 11:01 A.M., the Dietary Supervisor provided a second
outside food policy and said they were unaware if a copy was located at the nurse’s desk,
but he/she believed one had previously been given to the Director of Nursing (DON).
Record review on 9/11/18 at 12:17 P.M., of the policy entitled Food from Outside (Brought
by Families) provided by the DS showed the same document obtained online, without the
corporate logo added to the upper right corner.
During an interview on 9/11/18 at 1:45 P.M., Licensed Practical Nurse (LPN) A said:
– There was a resident refrigerator in a room behind the nurse’s desk marked soiled
utility, and showed its location;
– That there were only two TV dinners in the freezer that were dated, but he/she could not
read the names on them;
– Resident’s diets would be checked if food came in for them;
– He/she could not explain the facility’s procedures to be followed in the event of food
being brought in, and
– They knew where a policy would be if there was one, however, upon looking in a binder at
the nurse’s desk entitled Nursing Key Policies and Procedures he/she could not readily
find one.
On 9/12/18 at 10:09 A.M., a request for copies of any in-services on the outside food
policy was made with the Social Services Director, but none were forthcoming.
On 9/12/18 at 11:17 A.M., a request for copies of any in-services on the outside food
policy was made with the Regional Nurse who said he/she didn’t think any in-services had
been done as they’re just now rolling it out in this area, but they would check. None were
forthcoming.
During an interview on 9/12/18 at 1:42 P.M., LPN B said:
– Some residents have their own refrigerators for food brought in;
– There is also a refrigerator behind the nurse’s desk for those who don’t have one;
– One resident has Gatorade brought in and they put his initials on them and store them
for him, and
– He/she did not know of any written policy or procedures food brought in by families.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure infection
control practices to prevent cross contamination were implemented while performing cares

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
for three sampled residents (Resident #2, #10 ,#289 and #26) and to ensure two sampled
resident’s catheter (a tube inserted into the bladder to drain and collect urine) bag was
kept below the bladder during a transfer (Resident #2 and #289) out of 16 sampled
residents. The facility census was 42 residents.
Record review of the facility’s Handwashing/Hand hygiene policy and procedure dated
(MONTH) (YEAR), showed the facility considers hand hygiene the primary means to prevent
the spread of infection. All personnel shall be trained and regularly in-serviced on the
importance of hand hygiene in preventing the transmission of healthcare associated
infections. The policy showed:
-Hand hygiene products and supplies should be readily available and convenient for staff
use.
-(Staff should) wash hands with soap and water when hands are visibly soiled, after
contact with a resident with infections, before and after assisting a resident with
toileting/brief change or perineal care.
-Use an alcohol-based hand rub, or soap and water before and after direct contact with
residents, before preparing or handling medications, before and after handling an invasive
device, before donning sterile gloves, before handling clean or soiled dressings, before
moving from a contaminated body site to a clean body site during resident care, after
contact with a resident’s intact skin, after contact with bodily fluids, after handling
used dressings or contaminated equipment, after contact with objects in the immediate
vicinity of the resident, after removing gloves and before and after entering isolation
precaution settings.
-Hand hygiene is the final step after removing and disposing of protective equipment.
-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use
along with routine hand hygiene is recognized as the best practice for preventing
healthcare associated infections.
1. Record review of Resident#10’s Face Sheet showed he/she was admitted to the facility on
[DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated
assessment tool to be completed by facility staff for care planning) dated 7/26/18, showed
he/she:
-Had cognitive loss with memory dysfunction;
-Needed total assistance with bathing, dressing, toileting, transferring and mobility and
-Had limited range of motion in his/her upper and lower extremities.
Observation on 9/11/18 at 12:05 P.M., showed the resident lying in his/her bed, which was
low to the ground. The resident’s roommate was also in the room in his/her bed. The
resident began calling out. Certified Nursing Assistant (CNA) C immediately responded,
knocked on the door and the resident asked if it was time for lunch. CNA C said yes and
told the resident that they were going to get him/her up. The following occurred:
-CNA C, without washing his/her hands, put on gloves, removed the floor mat beside the
resident’s bed and put the resident’s bed up. CNA C then said he/she was going to check
the resident for continence and provide incontinence care;
-Without de-gloving, washing or sanitizing his/her hands, CNA C removed the resident’s
brief and began performing incontinence care on the resident;
-CNA D, who was also in the room, washed his/her hands and gloved, then came over to
assist CNA C with rolling the resident to the side to complete the resident’s care. When
they were finished cleaning the resident, CNA D began to bag up the soiled linen. CNA C
placed discarded the resident’s soiled brief and his/her soiled gloves in the trash bag
CNA D was holding;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-CNA C then, without washing his/her hands, put on a new pair of gloves;
-CNA D sat the trash bag down and, without de-gloving and washing his/her hands, began
putting cream on the resident’s bottom area while CNA C assisted with the positioning of
the resident. CNA C then obtained a clean brief from the resident’s closet;
-CNA D, without de-gloving and washing his/her hands or changing gloves, then began
assisting with putting a clean brief on the resident;
CNA C and CNA D both assisted with putting the resident’s clothing on and putting the
sling under resident so they could transfer the resident to his/her specialized
wheelchair;
-CNA C, without de-gloving and washing his/her hands, then took the resident out of the
room and down to the dining area and
-CNA D de-gloved and without washing his/her hands, took the bag of soiled linen and
trash, and left the resident’s room.
During an interview with CNA C and CNA D on 9/11/18 at 1:45 P.M., CNA D said they didn’t
wash their hands before they began care of the resident. CNA C said that they were
supposed to wash their hands when they go from performing a dirty task to a clean task and
then again before they leave the resident’s room. CNA D said he/she was not aware if the
facility had hand sanitizer available for them to carry around in their pocket, but he/she
understood why they should wash their hands after completing a dirty task if hand
sanitizer was not available.
2. Record review of Resident #2’s Face Sheet showed he/she was admitted to the facility on
[DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s Annual MDS dated [DATE], showed he/she:
-Was cognitively impaired, with disorganized thought , inattention and altered
consciousness;
-Needed extensive assistance with bathing, dressing, toileting, eating, mobility and
ambulation and
-Was not able to answer questions related to activity preferences or likes.
Observation on 9/12/18 at 7 :10 P.M., showed the resident in his/her room sitting up in
his/her specialized wheelchair with CNA B standing beside him/her. CNA B was wearing
gloves and had attached the Hoyer lift to the sling (that the resident was sitting on) CNA
B said that he/she was waiting for the nurse to come to assist with the transfer. At 7:10
P.M. CNA E came into the room and said that he/she was going to assist with the resident’s
transfer. The following occurred:
-CNA E, without washing his/her hands or sanitizing, put on gloves and began to assist;
-CNA B mobilized the lift while CNA E positioned the resident and assisted with keeping
him/her safe;
-Once the resident was positioned in bed, CNA E and CNA B checked the resident for
incontinence and then covered the resident (he/she had a gown on) and pulled off his/her
pants;
-CNA E discarded his/her gloves and washed his/her hands and CNA B discarded his/her
gloves, but then without washing his/her hands, he/she took the resident’s clothing out of
the room.
During an interview on 9/14/18 at 2:37 P.M., Registered Nurse (RN) B said:
-Before they start care the nursing staff should wash their hands and every time they
change their gloves they should wash their hands;
-They should also wash their hands after completing a dirty task and again before leaving
the resident’s room and
-The catheter bag should always be below the bladder, even during transfers because the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
fluid in the bag could backflow up the tubing and into the resident’s bladder. It should
never be placed above the bladder.
During an interview on 9/14/18 at 3:10 P.M., the Director of Nursing (DON) said:
-Nursing staff should wash their hands upon entering the resident’s room, whenever they
remove their gloves, after performing a dirty task and before leaving the resident’s room
and
-When transferring a resident, the resident’s catheter bag should always be kept below the
resident’s bladder.
3. Record Review of Resident #26’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Care Plan dated 10/17/17 and revision date of 5/10/18
showed he/she:
-Was on Hospices services due [MEDICAL CONDITION] (CA), required as needed oxygen (O2)
usage for comfort care;
-Had activity of daily living (ADL) self care deficit related to his/her disease process;
-Required assistance from staff for transfer with Hoyer lift, bathing and shower as needed
and nursing staff and CNA was to report any changes in the resident to the charge nurse
and
-Had Urinary Tract Infection [MEDICAL CONDITION] and was on antibiotic (revised dated
5/4/18).
Record review of the resident’s progress noted dated 8/2/18 at 3:09 P.M., showed the
resident had received a new physician’s orders [REDACTED]. [REDACTED].
Record review of the resident’s Annual MDS dated [DATE], showed he/she:
-Had cognitive loss with memory dysfunction;
-Needed total assistance with bathing, dressing, toileting, transferring and mobility and
-Had a UTI in the last 30 day’s and was antibiotic therapy.
Record review of the resident’s POS dated 9/1/18 to 9/31/18 showed:
-Had physician’s orders [REDACTED].
-No documentation on POS of any medication for treatment of [REDACTED].
Record review of the resident nursing notes dated 9/2/18 at 4:42 P.M., showed:
-Team meeting notes for the resident;
-The resident was on hospice service for end [MEDICAL CONDITION] and
-He/she had a UTI and had been treated with antibiotic.
Record review of resident nursing notes dated 9/4/18 at 6:30 P.M. showed the resident had
been started on [MEDICATION NAME] 600 milligrams (mg)/ 1 gram (G) (an antibiotic) every 12
hours for a UTI and blood infection. No adverse reactions.
Observation of the resident’s transfer and peri care by CNA C, and Hospice Health Aid
(HHA) A on 9/11/18 at 10:45 A.M. showed:
-CNA C had already had gloves on his/her hands, attached the resident’s sling to the Hoyer
lift and explained what he/she was doing, slowly raised the resident and moved over to
bed;
-then lowered the resident to the bed without difficulty;
-HHA A guided the resident, while facility CNA C operated Hoyer and moved the resident
with the Hoyer;
-Unhooked the resident from the Hoyer;
-With the same gloves on his/her hands the CNA C begin to lower the resident’s pants to
see if wet and to provided care for the resident;
-The Hoyer sling remained under the resident during peri care;
– With the same gloved hands, the CNA C provide peri care;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-The resident had redden area around the thigh area and under his/her groin area;
-CNA C said he/she will apply barrier skin cream to those areas,
-With one wipe with cleansing clothe at a time the CNA C cleaned the resident;
-With same gloves on his/her hands, the CNA C rolled the resident’s brief down;
-Had the resident rolled to his/her side, cleaned back side;
-With the same soiled gloves, he/she obtain a new clean brief;
-CNA C removed gloves, he/she did not wash his/her hands or use hand sanitizer prior
applying new pair of gloves;
-Then applied new brief under the resident and with gloved hand applied barrier cream to
resident’s redden areas;
-He/she removed his/her gloves and applied new pair of gloves to his/her hands and
finished dressing the resident;
-CNA did not wash his/her hands or use hand sanitizer prior applying the new pair of
gloves;
-Resident was then transferred back to his/her wheel chair and
-Resident had complaint of tenderness of the groin area during care.
During an interview on 9/12/18 at 9:10 P.M., with CNA E said:
-CNA’s and other staff are to wash their hands when enter the resident room and before
exit the resident room;
-During resident’s care should have gloves on his/her hands and when remove gloves should
wash hands or use hand sanitizer;
-You should change your gloves and wash hands from a dirty process to a clean process;
-When transfer a resident, nursing staff and CNA should wash their hands and place clean
gloves on their hands;
-After transferring of the resident, you need to remove your gloves and wash your hands
and
-If provide care after the resident’s transfer, wash your hands then apply a new pair
clean gloves on his/her hands.
During an interview on 9/14/18 at 3:01 P.M., the DON said he/she would expect nursing
staff and CNA to change gloves and wash hand between a clean and dirty process.
4. Record review of Resident #289’s face sheet showed he/she was admitted on [DATE] with
the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (the gradual loss of kidney function);
-UTI and
-Type 1 Diabetes (a long term condition in which the pancreas produces little or no
insulin to lower blood sugar)
Record review of the resident’s Significant change MDS dated [DATE] showed:
-He/she was cognitively intact and
-He/she had a indwelling catheter (a flexible plastic tube inserted into the bladder that
remains there to provide continuous urinary drainage to a urinary drainage bag).
Observation on 9/11/18 at 1:36 P.M., showed the resident had his/her catheter tubing
connected to a urinary drainage bag:
-He/she had the bag attached by straps to the front side of his her upper leg;
-He/she was lying on their back in bed; and
-His/her urinary drainage bag was above his/her bladder allowing expelled urine to drain
back into the catheter tubing and return into the bladder.
During observation on 9/11/18 at 1:36 P.M., of catheter care the resident was lying in
his/her bed CNA C and CNA D performed hand hygiene by washing their hands and gloving
prior to the care:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-CNA C helped CNA D position the resident and helped hold the residents legs during cares;
-CNA D de-gloved and performed hand hygiene with each step of catheter care;.
-CNA D and CNA C rolled the resident toward CNA C’s side of the resident’s bed and removed
the padding from under the resident;
-CNA D removed his/her gloves and washed his/her hands re-gloved and placed a clean brief
under the resident;
-CNA C helped roll the resident toward CNA D and onto his/her back and reached across
opened the brief tabs and pressed them down onto the clean brief securing it to the
resident;
-CNA C and CNA D removed their gloves and placed them in the trash receptacle;
-CNA C left the room, failing to wash her hands
-CNA D washed her hands, asked the resident if he/she needed anything else, and then left
the room.
Observation on 9/13/18 at 12:44 P.M.,showed the resident returned from having lunch with
the urinary drainage leg bag attached to his/her upper leg allowing urine to return to
his/her bladder.
During an interview on 9/13/18 at 12:47 P.M., CNA F said:
-Urinary drainage bags need to be kept lower than the person’s hips and
-The urinary drainage bags should be kept in privacy covers.
During an interview on 9/14/18 at 3:48 P.M. the DON said:
-Urinary drainage bags need to be kept lower than the bladder to prevent contamination and
UTI’s;
-He/she expected staff to educate the resident to what should be proper placement of a
urinary leg bag when it is placed inappropriately;
-He/she said expectations of staff were that hand hygiene would be performed prior to
putting on gloves, when changing gloves between dirty and clean tasks and
-He/she expected hand hygiene to be done after removing gloves and at the completion of
any task with residents.

F 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Keep all essential equipment working safely.

Based on observation and interview, the facility failed to maintain one of two clothes’
dryers in working condition and to have a system in place to inform the administrative
leadership of the facility of the dryer not being in working condition. This practice
potentially affected the drying time of clothes in the facility. The facility census was
42 residents.
1. Observation on 9/12/18 at 2:44 P.M., showed a clothes’ dryer with an Out of Order sign
on it.
During an interview on 9/12/18 at 2:44 P.M., Laundry Aide A said that dryer has been out
of order for about a year.
During an interview on 9/13/18 at 10:20 A.M., the Housekeeping Supervisor said:
– He/she has been the Housekeeping Supervisor since (MONTH) (YEAR);
– There had been issues in getting clothes back to residents in a timely manner, because
the washer would be finished but the previous load is still drying;
– The laundry aides are always two loads behind because the washer could finish two loads
while the one dryer is still drying the former load before the next two loads are

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265275

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

09/14/2018

NAME OF PROVIDER OF SUPPLIER

BUTLER CENTER FOR REHABILITATION AND HEALTHCARE

STREET ADDRESS, CITY, STATE, ZIP

416 S HIGH STREET
BUTLER, MO 64730

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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completed and
– Sometimes, it could be two days before they could get the clothes back to the residents.
During an interview on 9/13/18 at 10:43 A.M., Resident #30 said sometimes it took longer
to get his/her clothes back and he/she had heard that the facility was down one dryer.
During an interview on 9/13/18 at 10:43 A.M., the Interim Administrator said he/she did
not know the clothes dryer was out of order.
During a phone interview on 9/17/18 at 1:26 P.M., the Regional Nurse said no one reported
the dryer to him/her as being out of order and the facility staff should fill out a
maintenance request form for items that are out of order.
During a phone interview on 9/18/18 at 10:48 A.M., the former Administrator said:
– The Maintenance Director had asked and asked for that clothes’ dryer to be repaired;
– No one from the corporate office replied about getting the clothes’ dryer repaired, and
– The new corporation took over the facility in (MONTH) (YEAR).
During a phone interview on 9/18/18 at 2:51 P.M., the Maintenance Director said the
following:
– In (MONTH) (YEAR), a company form the area came to the facility and gave a quote on how
much it would cost to fix the clothes’ dryer;
– That information was transmitted to the previous and current ownership groups,
– In (MONTH) (YEAR), the facility received a new washer and
– Getting the clothes’ dryer fixed became less of a priority at that time and has been
less of a priority since that time.