Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 River Valley Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and documented wandering and exit-seeking behaviors was not provided with a care plan addressing these issues, despite being assessed for elopement risk and having a Wander Guard device applied. Facility policy required such behaviors to be care planned, but the omission left staff without documented guidance for supervision and intervention.
A resident with COPD, ESRD, and diabetes was not assisted or reminded by staff to rinse her mouth after using a Trelegy Ellipta inhaler, despite facility policy and manufacturer instructions requiring this step to prevent oral infections. Staff interviews confirmed awareness of the requirement, but the step was missed during observed medication administration.
The facility failed to provide eight consecutive hours of RN coverage for multiple days over two periods, lacking RN presence for 12 days from March to May and 27 days from June to August. The facility did not have an RN staffing waiver and relied on the DON to cover RN duties when the census was below 60. Staff reported significant shortages, especially on weekends, leading to incomplete care tasks. The facility was in the process of hiring another RN after a recent departure.
The facility failed to maintain infection control precautions, including improper use of PPE for a resident with an MDRO, and inadequate cleaning of a mechanical lift and glucometers. A CNA did not wear a gown during high-contact care, and an LPN used incorrect cleaning methods for glucometers. The Infection Preventionist and DON did not conduct necessary audits.
A resident experienced a 48-hour delay in receiving a scheduled fentanyl patch due to an expired prescription and pharmacy delivery issues. Despite staff efforts to obtain a new prescription and communicate with the pharmacy, the delay persisted. The resident was given other pain medications, but the facility's policies for managing controlled substances were not effectively followed.
Failure to Develop and Implement Care Plan for Wandering Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who exhibited exit-seeking and wandering behaviors. Despite the resident being identified as having severe cognitive impairment and being assessed for wandering and elopement risk, there was no care plan addressing these behaviors or the use of a Wander Guard device. Documentation showed that the resident attempted to exit the facility, was evaluated for elopement risk, and had a Wander Guard applied, yet these interventions were not reflected in the resident's care plan. Facility policy required that residents with wandering or elopement risk receive adequate supervision and have their needs addressed in a person-centered care plan. Interviews with facility leadership confirmed that the omission of a care plan for wandering was an oversight, and that multiple staff were responsible for reviewing care plans. The lack of a care plan meant that staff did not have documented guidance on how to address the resident's wandering behaviors, contrary to facility policy and professional standards.
Failure to Ensure Mouth Rinsing After Steroid Inhaler Administration
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident with chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD), and type 2 diabetes rinsed her mouth after administration of the Trelegy Ellipta inhaler, as required by the physician's order and the manufacturer's prescribing information. The resident was cognitively intact and self-administered the inhaler, but staff did not supervise or remind her to rinse her mouth following use, which is necessary to prevent oral infections such as thrush due to the corticosteroid component in the medication. Observation confirmed that the resident was given the inhaler without being prompted or assisted to rinse her mouth afterward. Interviews with staff, including medication aides, the pharmacist, LPN, DON, and the administrator, revealed an understanding of the importance of mouth rinsing after steroid inhaler use, but also acknowledged that the required step was missed during the observed administration. Facility policy and the manufacturer's instructions both specify that medications should be administered as ordered and according to professional standards, including rinsing the mouth after inhaler use.
RN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for multiple days over two separate periods. Specifically, there was no RN on duty for 12 out of 92 days from March 1, 2024, through May 31, 2024, and for 27 out of 92 days from June 1, 2024, through August 31, 2024. The facility's policy requires RN coverage for at least eight consecutive hours a day, seven days a week, unless waived. However, the facility did not have an RN staffing waiver. The Director of Nursing (DON) was utilized to fulfill RN requirements when the patient census was below 60, but this was not sufficient to cover all required days. Interviews with staff revealed that the facility was experiencing significant staffing shortages, particularly on weekends, leading to incomplete assignments and care tasks being skipped or passed to the next shift. Certified Nursing Aides (CNAs) reported having to cut corners due to the high workload and lack of staff. The DON acknowledged the staffing issues and mentioned that agency staff and management were used to cover shifts when needed. The facility was in the process of hiring another RN after recently losing one, but at the time of the report, they were still short-staffed, particularly on the night shift.
Infection Control Deficiencies in PPE Use and Equipment Cleaning
Penalty
Summary
The facility failed to maintain proper infection control precautions in several instances. For one resident diagnosed with a multidrug-resistant organism (MDRO), staff did not adhere to enhanced barrier precautions (EBP) as required. A Certified Nursing Aide (CNA) provided a bed bath to the resident without wearing a gown, despite a sign on the resident's door indicating the need for gloves and a gown during high-contact care. The CNA mistakenly believed the other resident in the room was on EBP. The Infection Preventionist admitted to not conducting specific audits on rooms with residents on EBP, relying instead on staff to follow posted instructions. Additionally, the facility did not properly clean and disinfect equipment used for multiple residents. After using a mechanical lift to transfer a resident, staff failed to clean the lift before storing it. Furthermore, glucometers were not cleaned according to the manufacturer's instructions. An LPN used an alcohol pad instead of the recommended bleach wipes to clean glucometers after use, and another LPN was unaware of the proper cleaning procedure. The Director of Nursing acknowledged that staff were expected to follow the manufacturer's directions for cleaning glucometers but had not been auditing the process.
Failure to Timely Administer Fentanyl Patch
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident 14, who was prescribed a fentanyl patch to be applied every 72 hours for chronic pain management. On a scheduled change date, the prescription had expired, and the medication was not available, resulting in a 48-hour delay before a new patch was applied. This lapse occurred despite the facility's policy requiring controlled medications to be reordered when a minimum of a five-day supply remained. The deficiency was compounded by communication and procedural failures. The nursing staff, including LPNs and RNs, were involved in attempts to rectify the situation by contacting the pharmacy and the nurse practitioner for a new prescription. However, there were delays in the pharmacy's delivery, and a reported labeling error further complicated the timely administration of the medication. Despite these efforts, the resident went without the prescribed fentanyl patch for an extended period, although other pain medications were administered during this time. Interviews with staff and family members revealed a lack of awareness and coordination in handling the situation. The family member of Resident 14 expressed concern over the delay and potential withdrawal symptoms, although staff reported no observed signs of withdrawal. The facility's Director of Nursing and Administrator were unaware of the incident until informed by the surveyor, indicating a gap in internal communication and oversight. The facility's policies and procedures for managing controlled substances were not effectively implemented, leading to the deficiency.
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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) |
|---|---|---|---|---|
| The Seasons At Alexandria | 13.8 mi | ★★★★★ | 6 | 1 |
| Grant Healthcare And Rehabilitation | 14.8 mi | ★★★★★ | 8 | 0 |
| Coldspring Transitional Care Center | 15.2 mi | ★★★★★ | 1 | 0 |
| Woodcrest Nursing And Rehabilitation Center | 17.8 mi | ★★★★★ | 0 | 0 |
| Emerald Trace | 17.9 mi | ★★★★★ | 6 | 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.