Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Pines Of Dekalb during CMS and state inspections, most recent first.
Food storage and kitchen sanitation were deficient when a large section of the kitchen floor was missing tile and exposed rough cement beneath food prep equipment, and multiple food items were found in refrigerators without proper labels, dates, or intact containers. The DM identified an unlabeled container as sausage gravy from the prior day and stated cracked containers should be discarded, while other items in the kitchen and conference room refrigerators were also found with cracked lids or missing labels and dates.
A resident with renal insufficiency, DM, depression, frequent stool incontinence, and intermittent urinary catheterization was ordered Macrobid for a UTI, but the facility received a microbiology report showing the organisms were resistant to Nitrofurantoin. The chart lacked clear documentation that the physician was notified of the resistance or that a new treatment was started when the lab results were reviewed, and the documentation did not show whether the microbiology report was communicated to the physician.
A resident with an NG tube for nutrition due to a hiatal hernia experienced improper tube management at the facility. The facility lacked specific physician orders for handling blockages, leading to an incident where a nurse used Coke to unblock the tube, contrary to best practices. The DON acknowledged the absence of a policy for NG tube care, and staff were expected to follow best practices, which were not adhered to in this case.
A resident with a left below the knee amputation had a dressing that was not changed for 12 days, contrary to physician orders and facility policy. The DON acknowledged the oversight, and the facility failed to document the dressing application or obtain a physician order for the dressing changes. The resident's care plan did not include specific interventions for the dressing changes observed.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store and label leftover foods and maintain kitchen sanitation for 68 of 68 residents served food prepared in the kitchen. During observation, a 2 foot by 24 foot section of kitchen floor was missing tile and exposed rough textured cement beneath a prep table, refrigerator, and flat top grill. The Dietary Manager stated the facility had experienced a sewer problem about two months earlier and the floor had been removed to repair a pipeline, and she was not aware of any definite plan to replace the flooring. The Director of Maintenance stated he had exchanged text messages about estimates for tile replacement, but no estimates had been conducted. In the kitchen refrigerator, a clear plastic container holding a white lumpy substance was observed with a cracked lid and no label or date; the Dietary Manager identified the item as sausage gravy from the previous day and stated it should have been labeled and dated. Additional containers of applesauce, fruit cocktail, and pears had cracked lids that allowed air into the containers, and the Dietary Manager stated cracked storage containers should be discarded and only intact containers used. In the conference room refrigerator, a cookie in a plastic bag was dated 7/24, a styrofoam takeout container with a resident's name was not dated, a freezer bag containing 9 ice cream cups had no label or date, and a large container of cookies and cream ice cream was not labeled and dated. A CNA stated the cookie should have been discarded after 3 days and all items should have been labeled and dated, and the Administrator stated all food items should be labeled and dated and floors should be intact and only undamaged storage containers should be used.
Delayed Response to Resistant UTI Culture Results
Penalty
Summary
The facility failed to ensure timely treatment of a urinary tract infection for one resident with diagnoses including renal insufficiency, diabetes mellitus, and depression. The resident’s quarterly MDS indicated a BIMS score of 14, frequent stool incontinence, and intermittent urinary catheterization. A physician order dated 7/28/25 directed Macrobid 100 mg by mouth twice daily for a UTI through 8/4/25 at 8:00 PM, and the MAR showed Nitrofurantoin was started on 7/28/25 at 8:00 PM. A microbiology report faxed to the facility on 7/29/25 at 11:42 AM identified Klebsiella pneumoniae and Escherichia coli that were resistant to Nitrofurantoin. Progress notes reviewed on 7/31/25 lacked documentation that the physician was notified of the antibiotic resistance or that a new treatment was initiated based on the lab results between 7/29 and 7/31/25. A handwritten note on the urinalysis paperwork indicated the physician was notified on 7/29/25 and no new orders were received, but it did not show whether the microbiology report was communicated to the physician. The DON later documented that the physician was notified of the resistance and an appropriate antibiotic was ordered, and stated the nurse phone message with all three pages of urinalysis results was sent on 7/29/25.
Improper Management of NG Tube in Resident
Penalty
Summary
The facility failed to ensure proper management and care of a nasogastric (NG) tube for a resident who required it for nutrition due to a worsening hiatal hernia. During an observation, it was noted that the resident had an NG tube in place, but the facility did not have specific physician orders for managing blockages in the tubing. On one occasion, staff were unable to administer the nutritional formula Jevity due to a blockage, and the resident was sent to the hospital following orders from a Nurse Practitioner. On another occasion, a Registered Nurse used a carbonated beverage, Coke, to unblock the tube after medication administration, which was against best practice guidelines. The Director of Nursing (DON) confirmed that the facility lacked a policy for NG tube maintenance and care, and staff were expected to follow best practices in such cases. The use of Coke to unblock the tube was inappropriate, as it could worsen the occlusion by causing proteins in the formula to precipitate within the tube. The recommended method for unblocking involved using warm water and a syringe, as outlined in best practice guidelines. The failure to follow proper procedures and lack of specific orders for managing blockages contributed to the deficiency in care for the resident with the NG tube.
Failure to Follow Physician Orders for Dressing Changes
Penalty
Summary
The facility failed to ensure that physician orders were obtained and followed for dressing changes for a resident with a left below the knee amputation. On observation, the dressing on the resident's amputation site was dated 8/22/24, indicating it had not been changed for 12 days. The Certified Nurse Aide (CNA) was unaware of the dressing, and the Director of Nursing (DON) acknowledged that the dressing should have been changed every 3 to 5 days. The facility's policy required a physician order for treatment and documentation of wound care, which was not adhered to in this case. The resident, who had a history of diabetes, peripheral vascular disease, and a left below the knee amputation, was receiving wound care and antibiotics for an infection at the amputation site. The resident's care plan included interventions for skin integrity and wound care, but there were no specific orders for the dressing changes observed. The resident's wound care records indicated that the dressing was to remain in place until a follow-up orthopedic appointment, but subsequent orders for dressing changes were not documented. Interviews with the DON revealed that the dressing application was not documented, and a physician order for the dressing was not obtained. The facility's policy required documentation of preventative measures and physician orders for resident care, which were not followed in this instance. The lack of adherence to these policies resulted in the deficiency noted by the surveyors.
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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) |
|---|---|---|---|---|
| Park View Care Center | 6.6 mi | ★★★★★ | 9 | 0 |
| Auburn Village | 8.9 mi | ★★★★★ | 2 | 0 |
| Betz Nursing Home | 9.4 mi | ★★★★★ | 1 | 0 |
| Vancrest Of Hicksville | 11.7 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 15 mi | ★★★★★ | 11 | 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.