Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Butte Senior Living during CMS and state inspections, most recent first.
A facility failed to prevent cross-contamination during wound care for a resident with stage III pressure ulcers. The LPN did not adhere to hand hygiene protocols, used contaminated scissors, and placed supplies on bed linens. The resident, admitted with pressure ulcers and a history of infections, was not placed on enhanced barrier precautions until weeks later. The LPN also failed to change gloves between dressing changes and did not wear gloves during resident transfer, violating infection control policies.
The facility failed to ensure the Dietary Manager had the necessary credentialing, as required by regulations. A review of the DM's personnel file showed no evidence of completed training, and an interview confirmed the lack of required education and certification. The DM was enrolled in a course to obtain the necessary credentials, and a Registered Dietician visited the facility bi-weekly. This deficiency potentially affected food service for 26 residents.
The facility failed to maintain proper kitchen sanitation and food handling practices, affecting 26 residents. A dietary staff member used hand sanitizer instead of washing hands and handled food with bare hands. Observations revealed unsanitary conditions, including dusty fans, unlabeled frozen food, and a dirty microwave and ice machine.
The facility failed to provide adequate toileting and incontinence care for four residents who required substantial assistance with daily activities. One resident was not offered toileting assistance for over nine hours, resulting in a heavily soiled brief. Another resident was not checked for incontinence for four hours, leading to bowel and bladder incontinence. Staffing challenges were cited as a reason for not adhering to care plans that specified toileting assistance at specific times.
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in inadequate care and supervision. A resident with severe cognitive impairment was not offered toileting assistance for over nine hours, leading to a heavily soiled incontinence brief. Another resident with a history of wandering and falls required frequent 1:1 or 2:1 staff supervision, which was not adequately provided, impacting the care of other residents. Multiple residents experienced delayed toileting assistance, resulting in soiled incontinence products, and a resident experienced multiple falls due to inconsistent implementation of care plan interventions.
The facility failed to follow infection control protocols, leading to potential cross-contamination. Staff neglected hand hygiene and glove changes during resident care and did not clean mechanical lifts between uses. Enhanced Barrier Precautions were not implemented for a resident with MRSA history, as required.
The facility failed to report an incident where two cognitively impaired residents were seen kissing, which was not reported to the State Agency as required by the facility's abuse policy. Both residents had severe cognitive impairments and were unaware of the inappropriateness of their actions. The incident was reported internally but not to Adult Protective Services or the Department of Health and Human Services.
The facility failed to update care plans for two residents with severe cognitive impairments after an incident where they were observed kissing. Despite the incident being reported, the care plans did not include interventions related to this behavior. Interviews confirmed the care plans were not revised to address the incident.
The facility failed to prevent falls for two residents with severe cognitive impairments, leading to repeated incidents and injuries. Despite interventions like motion sensors and appropriate footwear, the facility did not consistently implement new measures or determine causal factors. Interviews confirmed the facility's shortcomings in fall prevention and management practices.
A survey revealed an 8% medication error rate in an LTC facility, exceeding the acceptable 5%. Errors included an LPN preparing an incorrect insulin dose for a diabetic resident due to not checking the MAR, and an MA failing to ensure a resident consumed Miralax, yet documenting it as given. The facility's policy on medication administration was not followed.
A nurse aide, not certified in Nebraska, administered oxygen to a resident, which is outside the scope of practice for CNAs. The facility's job description did not include oxygen administration as a responsibility, and the DON confirmed the NA was not qualified for this task.
Failure to Implement Infection Control Measures During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care and did not implement enhanced barrier precautions for a resident with multiple pressure ulcers. The facility's policies on standard precautions and enhanced barrier precautions were not adhered to, as observed during a wound care procedure. The LPN involved did not perform hand hygiene before putting on clean gloves and after removing soiled gloves, which is a critical step in preventing infection. Additionally, the LPN used contaminated scissors to cut tape and placed wound care supplies directly on the resident's bed linens, further increasing the risk of infection. The resident involved was admitted with stage III pressure ulcers on the left hip, thigh, and shoulder. The resident had a history of non-traumatic brain dysfunction, pneumonia, dementia, and malnutrition, and was dependent on staff for personal care. The resident's pressure ulcers were present upon admission and had shown signs of infection, as indicated by the need for multiple courses of antibiotics. Despite these conditions, the resident was not placed on enhanced barrier precautions until several weeks after admission, which was a significant oversight by the facility. During the observed wound care procedure, the LPN failed to change gloves between dressing changes for different wound sites and did not perform hand hygiene between these tasks. The LPN also did not wear gloves when assisting in transferring the resident, which is a requirement under enhanced barrier precautions. These actions and inactions contributed to the deficiency, as they did not align with the facility's infection control policies and increased the risk of cross-contamination and infection for the resident.
Dietary Manager Lacks Required Credentialing
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary credentialing to meet regulatory requirements for their position. This deficiency was identified through a review of the facility's job description for the Director of Dining Services, which was revised on 7/18/24, and required the DM to perform duties in accordance with current federal and state regulations. The job description also stipulated that the DM should meet current requirements established by regulatory agencies or be enrolled in a class to meet such requirements. However, a review of the DM's personnel file revealed no evidence of completed required training. An interview with the DM confirmed that they did not have the education, credentialing, or certification required for the position. The DM acknowledged enrollment in a class/course to obtain the necessary education and credentials. Additionally, it was noted that a Registered Dietician visited the facility every other week, but there was no other staff employed at the facility with the required qualifications. This deficiency had the potential to affect the food service provided to 26 residents who were served food from the kitchen.
Deficiencies in Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and food handling practices, which had the potential to affect all 26 residents who consumed food prepared in the facility's kitchen. Observations revealed that a dietary staff member, identified as DC-J, did not wash hands with soap and water as required, instead using hand sanitizer before handling food. DC-J used bare hands to handle food items such as bread and cheese, and later used gloved hands to touch various kitchen surfaces and utensils without changing gloves, violating the facility's policy on bare hand contact with food and glove use. Further inspection of the kitchen revealed several sanitation issues, including plastic scoops left inside flour and sugar bins with handles touching the food, a dusty fan blowing over a storage area, a chest freezer with frost and ice accumulation, and repackaged food items in the freezer that were not labeled or dated. Additionally, the microwave had a heavy layer of food splatter, and the ice machine had a significant build-up of lime deposits and dust. The facility's kitchen cleaning checklist indicated that these areas should have been cleaned regularly, but there was no evidence that the cleaning had been completed.
Failure to Provide Adequate Toileting Assistance
Penalty
Summary
The facility failed to provide adequate assistance with toileting and incontinence care for four residents who required substantial to maximal assistance with activities of daily living. Resident 11, who had severe cognitive impairment and was frequently incontinent, was not offered toileting assistance or checked for incontinence from 7:30 AM until 5:00 PM, resulting in a heavily soiled urinary incontinence brief. The care plan for Resident 11 specified assistance with toileting before and after meals, midafternoon, at bedtime, and as needed, but this was not adhered to due to staffing challenges. Resident 7, who was dependent on staff for all transfers and toileting, was not offered toileting care from 6:30 AM until 10:33 AM, during which time the resident was found to be incontinent of both bowel and bladder. The care plan required assistance with toileting before and after meals, but this was not provided. Similarly, Resident 3, who required maximal assistance with toileting hygiene, was not checked for incontinence from 7:00 AM until 2:15 PM, resulting in a heavily soiled pull-up. The care plan for Resident 3 also specified assistance with toileting at specific times, which was not followed. Resident 6, who required maximal assistance for toileting hygiene, was not offered toileting care from 9:00 AM until 2:00 PM, resulting in a soiled pull-up. The care plan for Resident 6 required assistance with toileting before and after meals, midafternoon, at bedtime, and as needed, but this was not provided. Interviews with staff confirmed that the residents were not toileted as per their care plans due to staffing levels, leading to prolonged periods without toileting assistance and resulting in incontinence issues.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of several residents, resulting in inadequate care and supervision. Resident 11, who has severe cognitive impairment and requires substantial assistance with toileting, was not offered toileting assistance for over nine hours, leading to a heavily soiled incontinence brief. Similarly, Resident 7, who is dependent on staff for toileting and is always incontinent, was not provided with timely toileting care, resulting in incontinence of both bowel and bladder. Staff interviews confirmed that the lack of sufficient staffing made it difficult to meet the residents' toileting needs in a timely manner. Resident 77, with severe cognitive impairment and a history of wandering and falls, required frequent 1:1 or 2:1 staff supervision due to exit-seeking and aggressive behaviors. The facility's staffing levels were inadequate to provide the necessary supervision, impacting the ability to meet the needs of other residents. The ongoing behaviors of Resident 77 necessitated significant staff attention, which diverted resources from other residents, further highlighting the staffing deficiencies. Resident 22 experienced multiple falls over several months, with interventions either not being implemented or delayed. The resident's delusions and hallucinations contributed to the falls, and the facility did not consistently implement care plan interventions to prevent these incidents. Additionally, Resident 3 and Resident 6, both with severe cognitive impairments and incontinence issues, were not provided with timely toileting assistance, resulting in soiled incontinence products. The Director of Nursing confirmed that the current staffing levels were insufficient to maintain toileting schedules, prevent falls, and address resident behaviors effectively.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, leading to potential cross-contamination among residents. Observations revealed that staff members, including nursing assistants and medication aides, consistently neglected to perform hand hygiene before and after resident care, as well as during glove changes. This was evident in multiple instances where staff entered resident rooms, provided incontinence care, and administered medications without washing hands or using hand sanitizer. Additionally, staff often failed to change gloves between dirty and clean tasks, further increasing the risk of contamination. The use of mechanical lifts for resident transfers also highlighted lapses in infection control practices. Staff did not clean or disinfect the sit-to-stand mechanical lifts between uses for different residents, despite the facility's policy requiring such measures to prevent microorganism transmission. This oversight was confirmed by the Director of Nursing and the Administrator, who acknowledged that the lifts were used for multiple residents and should have been cleaned after each use. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a history of Methicillin-resistant Staphylococcus Aureus (MRSA), as required by their care plan. The absence of EBP measures, such as the use of gowns and gloves during high-contact care activities, was noted during several observations. The Director of Nursing confirmed that EBP should have been in place for this resident, indicating a failure to follow established infection control protocols.
Failure to Report Incident Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report an incident involving two residents to the State Agency, as required by their abuse policy. The incident occurred when Resident 3, who had severe cognitive impairment and a diagnosis of non-traumatic brain dysfunction and dementia, was seen kissing another resident, Resident 23, who also had severe cognitive impairment and a diagnosis of Alzheimer's Disease and non-Alzheimer's Dementia. Both residents were unaware of the inappropriateness of their actions due to their cognitive impairments. The staff separated the residents and monitored them to prevent further interaction, and the incident was reported internally to the Administrator and charge nurse by the Social Services Director. Despite the internal reporting, the facility did not report the incident to Adult Protective Services (APS) or the Department of Health and Human Services (DHHS) as required by their policy. The facility's policy mandates that any act against a vulnerable adult, including inappropriate sexual conduct, must be reported to APS. The Administrator confirmed during an interview that the incident was not reported to the State Agency. The failure to report this incident represents a deficiency in adhering to the facility's abuse policy and state regulations.
Failure to Update Care Plans for Residents with Behavioral Incidents
Penalty
Summary
The facility failed to review and revise the care plan interventions related to behaviors for two residents with severe cognitive impairments. Resident 3, diagnosed with non-traumatic brain dysfunction, non-Alzheimer's dementia, and unspecified dementia with behavioral disturbances, was involved in an incident on 10/14/24 where they were observed kissing another resident, Resident 23, in the living room. Both residents were cognitively unaware of the inappropriateness of their actions. Despite the incident being observed and reported by the Social Services Director, the care plan for Resident 3, last revised on 10/10/24, did not include any interventions related to this behavior. Similarly, Resident 23, who has severe cognitive impairment and a history of kissing a male resident, did not have their care plan updated to reflect the incident on 10/14/24. The care plan, last revised on 10/10/24, included instructions for staff to redirect the resident by explaining the behavior was not acceptable. However, there was no documentation of interventions related to the incident with Resident 3. Interviews with the MDS Coordinator and the Administrator confirmed that the care plans for both residents were not updated to include behavior interventions following the incident.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to adequately address and prevent falls for two residents, leading to repeated incidents and injuries. Resident 22, with severe cognitive impairment and a history of falls, experienced numerous falls over several months. Despite interventions such as a scoop mattress, motion sensors, and appropriate footwear, the facility did not consistently implement new interventions or determine causal factors for the falls. The resident continued to experience delusions and hallucinations, contributing to the falls, and there was a delay in medication reviews and adjustments. Resident 77, also with severe cognitive impairment and a history of falls, experienced multiple falls without adequate identification of causal factors or development of new interventions. The resident was found on the floor multiple times, and although interventions such as gripper socks and lowering the bed were eventually implemented, they were not consistently applied. The facility's failure to revise and implement effective fall prevention measures contributed to the ongoing risk of falls for this resident. Interviews with the Director of Nursing confirmed the facility's shortcomings in implementing new interventions and determining causal factors for falls. The facility's risk management policy required incidents to be reported, investigated, and reviewed, but this was not effectively carried out for Residents 22 and 77. The lack of adequate supervision and timely intervention adjustments resulted in repeated falls and injuries, highlighting deficiencies in the facility's fall prevention and management practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an 8% error rate observed during a survey. This was based on 25 opportunities for medication administration, where two errors were identified. The facility's policy on medication administration, which emphasizes adherence to the 5 Rights of medication administration and the use of the Medication Administration Record (MAR), was not followed in these instances. One of the errors involved a resident with diabetes who was dependent on staff for all activities of daily living and required daily insulin injections. During a medication pass, an LPN prepared to administer an incorrect dose of insulin to the resident. The LPN failed to check the MAR before preparing the insulin dose, relying instead on a typewritten note that led to the preparation of 3 units instead of the correct 6 units for the resident's blood glucose level. The error was identified and corrected only after intervention by a surveyor. Another error involved a resident who was prescribed Miralax to prevent constipation. An MA prepared the correct dose of Miralax and delivered it to the resident but did not ensure the resident consumed it. The MA then inaccurately documented the medication as administered. The Director of Nursing confirmed that staff are required to witness the complete consumption of all medications and that the MAR should be used to ensure accurate medication administration.
Unqualified Staff Administering Oxygen
Penalty
Summary
The facility failed to ensure that qualified staff were administering oxygen to a resident, leading to a deficiency. During an observation, a nurse aide (NA) was seen assisting a resident with toileting and then turning on the resident's oxygen concentrator and placing a nasal cannula on the resident. This action was performed despite the NA not being certified to administer or manage oxygen in Nebraska, as confirmed by the NA herself and the Director of Nursing (DON). The NA had a Medication Aide Certification in Minnesota but was not certified in Nebraska, which would require retesting. The facility's job description for Certified Nursing Assistants (CNAs) did not include the administration or provision of medications or oxygen as part of their responsibilities. The DON confirmed that the NA was not qualified or trained to administer or interrupt the flow of oxygen. This incident highlights a failure in ensuring that staff had the appropriate competencies to care for residents, specifically in the administration of oxygen, which is outside the scope of practice for a CNA without the necessary certification.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Andes Senior Living | 22.7 mi | ★★★★★ | 3 | 0 |
| Parkside Manor | 26.4 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Society - Atkinson | 27.6 mi | ★★★★★ | 16 | 0 |
| Good Samaritan Society - Wagner | 30.4 mi | — | 0 | 0 |
| Accura Healthcare Of O'neill | 32.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.