Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Taylor County Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that kitchen staff did not follow facility policy or professional standards for safe food handling. Large tubes of ground beef were removed from the freezer and left in a basin on a counter for an unknown number of hours instead of being thawed under refrigeration or under properly controlled running water, contrary to written thawing procedures. In a separate incident, a staff member spilled raw liquid eggs on a food preparation surface and wiped the spill with paper towels without using the required cleaning and sanitizing solutions and then placed a box of frozen biscuit dough on the un-sanitized area before returning it to the freezer.
MDS Coding Error for Tracheostomy Care: A resident with a permanent tracheostomy site had multiple MDS assessments that did not code tracheostomy care in special treatments/procedures, despite the MDS manual requiring it when performed in the prior 14 days. The resident was observed with a clean, dry, intact tracheostomy site and stated she could cover the opening to talk and did not need oxygen. An LPN AC acknowledged the assessments were missed and should have reflected the resident’s tracheostomy status.
A resident with moderate cognitive impairment had ongoing right upper tooth and gum pain, redness, edema, difficulty chewing, darkened gums and teeth, and broken teeth, yet had not seen a dentist. Staff interviews showed confusion over who coordinated dental services, no dental visit had been requested for the resident in the prior year, and concerns were raised about the resident’s ability to afford dental premiums.
A resident assessed to need two-person assistance for bathing due to hemiplegia and muscle weakness was only assisted by one staff member, leading to a fall and injury. Interviews confirmed the care plan was not followed, despite staff awareness of the requirement.
A resident, assessed as needing two-person assistance for bathing due to physical impairments, was only assisted by one staff member, resulting in a fall and head injury. The facility's policy required adequate supervision to prevent such accidents, but a CNA proceeded alone, leading to the incident. Interviews confirmed the need for two staff members, and the DON and Administrator acknowledged the misjudgment.
An LPN failed to perform proper hand hygiene during medication administration for four residents, contrary to the facility's infection control policy. The LPN did not wash hands between resident interactions or after glove use, as observed during medication pass. Interviews with the LPN, DON, and ICP confirmed the expectation for hand hygiene, highlighting a lapse in infection control practices.
The facility failed to offer additional fluids to residents on the secure unit during lunch meals, with observations showing residents attempting to drink from empty glasses and no water available in rooms. Staff interviews revealed infection control concerns as the reason for not keeping water in rooms, but hydration rounds were not adequately ensuring residents' hydration needs.
The facility failed to provide sufficient nursing staff in the secure unit during meals, leading to a resident taking other residents' food and beverages and inadequate staff to provide beverage refills. Interviews revealed that staffing issues have persisted for several months, with only one CNA assigned to the unit, causing unmet care needs for the residents.
The facility failed to provide routine indwelling urinary catheter care for a resident with a suprapubic catheter, as required by their policy. The resident, with neurogenic bladder and quadriplegia, confirmed that her catheter was changed monthly but not cleaned daily. Staff interviews and observations revealed confusion about responsibility for catheter care, contributing to the deficiency.
The facility failed to ensure nursing staff wore PPE and provided ADL care in a sanitary manner for a resident with a suprapubic catheter and bowel incontinence. One CNA did not don a gown and did not change soiled gloves before handling clean items, compromising infection control protocols.
Improper Thawing and Inadequate Sanitizing of Kitchen Food Preparation Surfaces
Penalty
Summary
The deficiency involves failure to follow the facility’s own policies and professional standards for safe food thawing. During an early morning kitchen tour, surveyors observed two ten‑pound tubes of ground beef sitting in a basin on top of the meat sink counter, with red and clear juices dripping into the bottom of the basin. The Assistant Dietary Manager stated the meat had been removed from the freezer at 3:00 a.m., and the Dietary Manager later described the correct thawing process as either in the refrigerator or in a basin under running cold water. The in‑service materials and facility policy specified that food should never be thawed at room temperature and should be thawed only under refrigeration, under running drinkable water at or below 70°F, by microwave if cooked immediately, or by cooking to proper internal temperature. The ground beef had been left out for an unknown number of hours before being placed under running water, contrary to these standards. The deficiency also involves failure to properly clean and sanitize a food preparation surface after a spill of raw liquid eggs. A staff member emptied seven liquid egg boxes into a cooking pan, then placed the empty boxes back into their original storage box while liquid eggs dripped onto the food preparation surface. After disposing of the empty boxes, the staff member returned to the preparation area and wiped the liquid egg spill using paper towels, without donning clean gloves and without using the designated cleaning and sanitizing solutions. The staff member repeated wiping the surface with additional paper towels and then placed a box of frozen biscuit dough directly on the area where the spill had occurred, later returning the box to the walk‑in freezer. Facility in‑service documentation required that food preparation surfaces be cleaned by scraping food bits, washing with the “green bucket” cleaning solution, rinsing with clean water, sanitizing with the “red bucket” sanitizing solution, and allowing the surface to air‑dry, which was not followed in this incident.
MDS Coding Error for Tracheostomy Care
Penalty
Summary
The facility failed to accurately code the MDS assessment for one resident, R48, by not documenting tracheostomy care in the special treatments/procedures section on multiple assessments. The resident’s record showed an admission date of 9/19/2022 and diagnoses that included a permanent tracheostomy site. Review of the MDS assessments with ARDs of 2/26/2025, 5/6/2025, 7/30/2025, and 10/23/2025 showed that tracheostomy care was not coded, even though the resident had a tracheostomy site and the MDS manual instructed that tracheostomy care be coded when performed while the resident is in the facility and within the past 14 days, including if the resident performs the care. During an observation on 1/6/2026, R48 was seen in her room with her tracheostomy site clean, dry, and intact. She stated she was able to cover the opening of the tracheostomy to talk and did not require oxygen use with the tracheostomy. During an interview on 1/8/2026, the LPN Assessment Coordinator stated the MDS assessments were missed and should have been coded to reflect R48’s tracheostomy status. The LPN AC also stated the facility did not have a specific policy for following the MDS and that she follows the MDS manual for coding.
Failure to Provide Dental Services for a Resident With Tooth Pain
Penalty
Summary
The facility failed to ensure routine or emergency dental services were provided for one resident with a BIMS score of 9 and documented tooth and gum pain. The resident’s change-of-condition assessments noted a reddened and slightly edematous area of the right upper gum, difficulty chewing on the right side, pain rated 5/10, darkened areas to the gums and teeth, and broken teeth. Orajel was administered on two dates, and the resident reported ongoing pain in the right upper teeth and gum area. The record and interviews showed that the resident had not seen a dentist despite repeated complaints of tooth pain and difficulty eating. The resident stated he had a bad tooth on the right upper side, a hole in the tooth, and had not seen the dentist. The SSA stated no dental visits had been requested for the resident in the prior twelve months and indicated uncertainty about whether the resident had enough money for dental premiums. The FC stated the resident had Medicaid with SSI only and that the dental premium exceeded the amount remaining after room and board. Other staff stated that nurses notify the SSA for dental services, that the SSA coordinates mobile dentistry, and that any nurse can make appointments, but the resident’s dental referral had not been arranged until later documentation noted an emergency dental visit was scheduled.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to ensure the development of a person-centered care plan for a resident, identified as R52, which resulted in actual harm. R52, who was assessed to require the assistance of two staff members for bathing due to conditions such as hemiplegia, hemiparesis, and muscle weakness, was only assisted by one staff member during a bed bath. This lack of adherence to the care plan led to the resident falling out of bed and sustaining a closed head injury and a laceration. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the resident was assessed as needing extensive assistance from two persons for bathing. However, CNA1 admitted to providing the bath alone, contrary to the care plan. The Director of Nursing and the Administrator both acknowledged that the care plan was not followed, which was expected to be adhered to for resident safety. The deficiency was documented under the facility's policy titled Patient's Plan of Care, which aims to promote person-centered care through comprehensive care plans.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as R52, was free from accidents and hazards, resulting in actual harm. R52, who was assessed as requiring the assistance of two staff members for bathing due to conditions such as hemiplegia, hemiparesis, and muscle weakness, was only assisted by one staff member during a bed bath. This inadequate supervision led to R52 falling from the bed and sustaining a closed head injury with a laceration. The facility's policy on Fall Management emphasizes the need for adequate supervision and assistance to minimize fall risks. R52's medical records indicated a moderate cognitive impairment and a dependency on staff for personal care, including a two-person assist for transfers and bathing. Despite these assessments, CNA1 provided a bed bath alone, during which R52 became dizzy and fell, hitting her head on an air conditioner. Interviews with staff and the resident confirmed that two staff members were typically required for R52's care due to her physical limitations. The Director of Nursing and the Administrator acknowledged that the care plan required two-person assistance and that CNA1's decision to proceed alone was a misjudgment, leading to the resident's injury.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during medication administration for four residents. The deficiency was observed when a Licensed Practical Nurse (LPN) did not perform proper hand hygiene practices between administering medications to different residents. The facility's policy on hand hygiene, which was revised in December 2023, clearly outlines the necessity of hand hygiene before and after patient contact, after glove removal, and when moving from a soiled to a clean environment. However, the LPN neglected to follow these guidelines during medication pass. The observations revealed that the LPN administered medications to four residents without performing hand hygiene before or after the process. For instance, after administering eye drops to a severely cognitively impaired resident, the LPN did not wash hands before leaving the room or before handling the medication cart. Similar lapses were noted with other residents, where the LPN failed to perform hand hygiene before obtaining medications and after administering them, despite handling items like medication cups and water cups. Interviews with the LPN, Director of Nursing (DON), and Infection Control Preventionist (ICP) confirmed the expectation for staff to perform hand hygiene between resident interactions and after glove use. The LPN admitted to forgetting to wash hands, while the DON and ICP reiterated the facility's policy and expectations for hand hygiene. The deficiency highlights a significant lapse in adhering to infection control protocols, which could potentially promote the spread of multi-drug resistant organisms within the facility.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to offer additional fluids to residents on the secure unit during two of three lunch meals observed. During observations, residents were only served one glass of tea with their meals, and no refills or additional fluids were offered before trays were removed. Nine residents were observed attempting to drink more tea from empty glasses, indicating a lack of adequate hydration. Additionally, there were no cups or pitchers of water in the resident rooms during multiple observations. Interviews with staff revealed that the absence of water in resident rooms was due to concerns about infection control and certain residents taking and drinking all the water. The Director of Nursing confirmed that the facility had stopped keeping cups of water in the secure unit for these reasons and stated that staff should ensure residents have water during hydration rounds. However, the observations indicated that this practice was not being followed, leading to the deficiency in maintaining adequate hydration for the residents.
Insufficient Nursing Staff in Secure Unit During Meals
Penalty
Summary
The facility failed to have sufficient nursing staff in the secure unit during meals, which led to a resident taking other residents' food and beverages and inadequate staff to provide beverage refills. During a lunch observation, one CNA was responsible for supervising 11 residents, feeding one resident, and managing the dining needs of others. This resulted in a resident taking a cup of coffee from another resident twice, causing the CNA to stop feeding to address the situation. Additionally, nine residents were not offered beverage refills during the meal. Similar observations were made on subsequent days, with only one CNA present, leading to unmet care needs for the residents. Interviews with CNAs and the DON revealed that the secure unit used to have two staff members, but due to staffing issues, only one person has been assigned for several months. The CNAs expressed difficulty in managing the residents' needs alone, especially during meals and showers. The DON acknowledged the staffing problems and stated that ideally, two staff members would be assigned to the unit. The lack of sufficient staff in the secure unit during meals placed the residents at risk for unmet care needs.
Failure to Provide Routine Indwelling Urinary Catheter Care
Penalty
Summary
The facility failed to ensure that nursing staff provided routine indwelling urinary catheter care for a resident with a suprapubic catheter. The resident, who had diagnoses including neurogenic bladder and quadriplegia, was assessed with moderate cognitive impairment and had an indwelling urinary catheter. The facility's policy required daily cleaning of the catheter insertion site with soap and water, but there was no evidence in the clinical record that this care was provided. The resident confirmed that her catheter was changed monthly but not cleaned daily. During an observation of personal hygiene tasks, catheter care was not provided by the CNAs, who believed it was the nurses' responsibility. The Director of Nursing stated that catheter cleaning was part of perineal care and the CNAs' responsibility, while the resident's nurse was unsure about who was responsible for cleaning the catheter tubing. The deficiency was identified through a review of the resident's clinical records, interviews with the resident and staff, and direct observation of care. The facility's failure to adhere to its own policy for suprapubic catheter care had the potential to increase the resident's risk of urinary tract infection. The lack of clarity among staff regarding responsibility for catheter care contributed to the deficiency, as evidenced by conflicting statements from the CNAs, the Director of Nursing, and the resident's nurse.
Failure to Follow PPE Protocols and Sanitary Practices
Penalty
Summary
The facility failed to ensure that nursing staff wore Personal Protective Equipment (PPE) following recommended practice and failed to ensure Activities of Daily Living (ADL) care was provided in a sanitary manner for one resident (R15). R15 had diagnoses including neurogenic bladder and quadriplegia, and was assessed as having an indwelling urinary catheter and being incontinent of bowel. The care plan required the use of PPE when providing care. During an observation, it was noted that an instructional sign titled Enhanced Barrier Precautions was posted on R15's door, indicating the need for hand hygiene and the use of gloves and gowns for high-contact activities. However, CNA CC did not don a gown and proceeded to assist with personal hygiene tasks, emptying the catheter drainage bag, dressing, bowel incontinence care, and transferring R15 without following the PPE guidelines. Additionally, during the provision of bowel incontinence care, CNA CC failed to change his soiled gloves before handling clean items and applying barrier cream, which compromised the sanitary conditions of the care provided. The Director of Nursing (DON) confirmed that R15 was on enhanced barrier precautions due to the suprapubic catheter and acknowledged the infection control concerns. These actions and inactions by the nursing staff had the potential to increase R15's risk of infection.
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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 Butler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miona Geriatric & Dementia Center | 12.4 mi | ★★★★★ | 8 | 0 |
| Oaks Nursing Home, Inc, The | 15.7 mi | ★★★★★ | 0 | 0 |
| Roberta Trails Of Journey Llc | 17.9 mi | ★★★★★ | 0 | 0 |
| Fort Valley Crossing Of Journey Llc | 20.9 mi | ★★★★★ | 9 | 0 |
| Montezuma Health And Rehabilitation | 21.3 mi | ★★★★★ | 2 | 0 |
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