Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Butler Rehab And Healthcare Center during CMS and state inspections, most recent first.
Kitchen sanitation deficiencies were observed during meal prep, including food debris on the can opener blade, debris under the 6-burner stove, dust on vent fans and a sprinkler head in the walk-in refrigerator, and dust and grease on light fixtures and ceiling vents. The Dietary Mgr stated the area under the stove may not have been cleaned for two weekend nights and that maintenance was expected to clean the refrigerator sprinkler head and fans.
A facility failed to keep resident rooms, shared restrooms, baths, dining areas, fans, vents, and a tube feeding pole clean and in good repair. Surveyors observed heavy dust in ceiling vents, grime and debris on floors, damaged and peeling flooring, dusty personal fans, and residue on a tube feeding pole base. Staff interviews showed housekeeping coverage gaps, limited cleaning tools, and uncertainty about who was responsible for cleaning certain items.
A facility failed to follow infection control practices during care for three residents. An LPN did not use gown-based EBP, used a barrier improperly for IV/PICC supplies, and handled a dropped alcohol wipe during IV medication administration for a resident on EBP. During insulin administration for a resident with diabetes, an LPN removed gloves and put on new ones without hand hygiene. A CMT also used a shared BP cuff without cleaning it before and after use during medication pass.
A resident with multiple chronic conditions, including stroke, dysphagia, CHF, AFib, CKD, and COPD, was assessed by the IDT as not safe to self-administer medications and was supposed to have all meds remain with staff. Surveyors nevertheless found an expired Vitamin D3 bottle with unidentified pills, an open bag of cough drops, and a cup of medications on the bedside table. The resident said the pills were taken daily and that the meds had been given that morning, while a CMT said he/she was unaware of any meds kept in the room and did not know where to find the self-administration assessment.
Failure to submit TPL form after resident death. A resident died with $8.68 remaining in the resident trust account, but review of trust fund records showed no TPL was submitted to MO HealthNet within the required 30-day timeframe. The BOM stated the form was not submitted because he/she believed the guardian was responsible for filing it.
Failure to Follow Criminal Background Check Policy: The facility did not follow its abuse prevention policy for criminal background checks for two employees. One employee’s background check was not obtained until well after hire, and another re-hired CNA’s background check was not re-run. The HR Director stated the original background check could not be found for one employee and that the prior HR Director did not re-run the check for the CNA.
A resident with dementia, confusion, and supervision needs fell from a chair and sustained a minor head abrasion, but the fall investigation was incomplete. The record did not fully document the circumstances of the unwitnessed fall, contributing factors, or a detailed injury description, and it did not show notification of the resident’s family or emergency contact despite the resident’s impaired decision-making capacity. Staff and the DON acknowledged that the incident report should have been comprehensive, but key elements were missing.
A resident with a colostomy, urostomy, paraplegia, and bladder dysfunction was providing most of his/her own ostomy care, but the chart lacked a physician order authorizing self-care and lacked a documented nursing self-care assessment. The care plan did not reflect the resident’s ability to manage the ostomies, even though staff and the resident stated he/she was doing the care with standby assistance and the DON, LPN, ADON, and ICP acknowledged the missing documentation.
A resident with a PEG tube, dysphagia, and severe cognitive impairment had a physician order for Fiber Source HN 1.2 at 47 ml/hr, but observations showed Diabetisource AC 1.2 was being run instead. The care plan noted tube feeding was needed but did not include the prescribed formula. Nursing documentation did not identify the formula being administered, and an LPN confirmed the formula in use did not match the order.
Uncovered oxygen equipment and tubing were observed for two residents. One resident with COPD, respiratory failure, and other respiratory conditions had CPAP and breathing treatment masks and tubing left uncovered on the dresser beside the machines while using continuous O2. Another resident with COPD and smoking history had nasal cannula tubing on the floor under clothing, not bagged, with dated tubing and an undated water container. Staff stated oxygen equipment should be bagged and kept off the floor when not in use.
A cold cottage cheese fruit plate was placed on room tray carts and left there without being returned to refrigeration, then delivered to residents on the 100 Hall at 52.1 F instead of at or near 41 F. The recipe identified 41 F as the CCP for service, and the Dietary Mgr said the plates likely warmed because they were on the same cart with hot foods and temperatures were not checked that day.
The facility failed to ensure pureed chicken was prepared to a smooth consistency for two residents on pureed diets. The DM made the chicken without adding thickener, did not have the recipe open during preparation, and did not taste it before serving. The surveyor found the pureed chicken was grainy, and the DM later acknowledged it was grainier than it should have been.
A resident with diabetes and traumatic brain injury, who wished to remain in LTC, was discharged to a homeless shelter after being sent to the hospital, with immediate discharge paperwork citing behavioral concerns. The discharge process lacked proper documentation, the resident's signature, and staff clarity on appropriate procedures.
A contracted PTA did not adequately explain therapy procedures or obtain informed consent before providing treatments to several residents, resulting in confusion and discomfort. Multiple residents with various medical conditions reported that the PTA initiated physical contact, including touching near the chest and abdomen, without prior explanation, causing them to feel uneasy or distressed. Interviews confirmed that proper communication protocols were not followed, leading to a deficiency in upholding residents' rights.
The facility failed to update care plans for several residents, including those with pressure ulcers, smoking supervision needs, and pain management. Observations and interviews revealed inconsistencies and lapses in accurately reflecting residents' current conditions and needs.
The facility failed to ensure proper TB screening for both residents and new employees. Four residents did not receive timely or documented TB tests, and two new employees started working without completing the required TB tests. Interviews revealed systemic issues in the administration and documentation of TB tests.
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three CNAs. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024.
The facility failed to develop a spend-down plan for two residents who maintained balances exceeding the Missouri Medicaid limit in their Resident Trust Fund accounts for more than one month. The Business Office Manager informed the residents of their excess balances but did not assist in creating a plan to manage the funds, risking the loss of Medicaid benefits.
The facility failed to accurately document a resident's advance directives, resulting in conflicting Full Code and DNR orders in the care plan. Interviews with staff revealed inconsistencies in updating and verifying the resident's code status, despite the resident's guardian providing verbal consent for Full Code.
The facility failed to follow its policy to conduct CBC and check the NA Registry for new employees before hiring. Employee B started work without a completed NA registry check, and Employee F's NA registry check was completed two days after their hire date. The BOM/HR and DON confirmed that these checks should be completed before new employees start working.
A resident with a history of cerebral infarction and hemiplegia did not receive necessary ROM treatment and services, including a previously ordered splint and therapy. The resident's left hand was observed to be contracted without any devices to maintain a neutral position, and interviews with staff confirmed the lack of appropriate interventions.
The facility failed to ensure that a physician reviewed and acted upon a pharmacist's monthly Drug Regimen Review (DRR) recommendations for a resident with a complex medical history. Despite the pharmacist identifying irregularities and making recommendations, no physician responses were found in the resident's medical record for two months, and a critical recommendation was not fully addressed in a third month.
The facility failed to ensure that two residents received necessary dental services for broken teeth. Both residents had significant dental issues, including missing and broken teeth, and expressed a desire to see a dentist. However, no dental appointments were made, and their care plans did not reflect any dental concerns. Staff interviews revealed systemic issues in handling dental care, including inadequate documentation and lack of follow-up.
Kitchen Sanitation Deficiencies
Penalty
Summary
The kitchen failed to maintain sanitary food service conditions during survey observation, with food debris found on the blade of the table top can opener, food particles and debris accumulated under the 6-burner stove, dust buildup on the vent fans and sprinkler head in the walk-in refrigerator, dust and grease on light fixtures, and dust inside the ceiling vents in the kitchen. During the lunch meal preparation observation, surveyors noted these conditions in multiple food preparation and storage areas, including over the microwave and dish storage area next to the reach-in refrigerator. In interview, the Dietary Manager stated dietary staff should clean the debris from under the stove every night, said the area under the 6-burner stove had probably not been cleaned for the two weekend nights before survey, and stated the dust on the light fixtures was related to the lack of a regular maintenance person. The Dietary Manager also said maintenance was expected to clean the sprinkler head and fans in the walk-in refrigerator because those tasks were beyond dietary staff duties.
Failure to Maintain Clean and Safe Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by allowing dust, debris, grime, and damaged flooring to remain in multiple resident areas and common spaces. Survey observations found heavy dust buildup in ceiling vents in the dining room, the 300 Hall Central bath, the 100 Hall Central Bath, the 200 Hall Central bath, shared restrooms between resident rooms 308 and 310 and between 306 and 304, and in resident room vents. Floors were observed with peeling, torn, or damaged surfaces in the shared restroom of resident rooms, the 300 Hall Central Bath, and restrooms in resident rooms, and floors in resident rooms 313, 307, 304, 302, 305, 303, 300, 111, 105, 106, and 102 were observed with grime, dust, hair, and debris. Personal fans in resident rooms 300, 303, 103, and 107 had heavy dust buildup, and the base of a tube feeding pole in a resident room had brown-colored substance on it. During interviews, the Housekeeping Supervisor said he/she had been away from duties for several months and that no one stepped up to serve in that role during the absence. The Housekeeping Supervisor stated that floors were expected to be mopped and swept daily, that personal fans had not really been cleaned since the former maintenance person left, and that the former maintenance person used to clean ceiling vents but no one was currently doing so. A housekeeper said scrapers were not available to remove grime from floors and that he/she did not want to move beds to clean under them if residents were sleeping. Another housekeeper said the damaged floor in the shared restroom of resident rooms had been like that for several months and that the restroom floor in a resident room was difficult to clean because of the damage. An LPN said he/she would have to find out who cleaned the tube feeding pole and did not clean it, while the ADON stated that housekeepers were responsible for cleaning the tube feeding pole.
Failure to Follow EBP, Hand Hygiene, and Equipment Cleaning Procedures
Penalty
Summary
The facility failed to ensure hand hygiene and Enhanced Barrier Precautions (EBP) for a resident with a physician’s order for EBP, and the facility policy did not include instructions for nursing staff to wear gowns with EBP or to use EBP for residents with indwelling devices. Resident #47 had diagnoses including MRSA carrier status and had orders for EBP related to an indwelling catheter and PICC line, along with daily IV ertapenem for a UTI. During observation, an LPN entered the room without a gown, placed IV medication and supplies on the resident’s overbed table without a barrier, handled the resident’s PICC line and IV medication, left the room to seek help mixing the medication, returned, and continued the IV administration without using a gown. The LPN also picked up an alcohol wipe package from the floor and used it on the resident’s PICC line. The DON stated the resident was on EBP, gowns should have been worn for IV medication administration and PICC line care, barriers should have been used for supplies, and the dropped alcohol wipe should have been discarded. The facility also failed to ensure hand hygiene between glove changes during insulin administration for a cognitively intact resident with diabetes who received insulin seven days per week. During observation, an LPN performed blood glucose testing and then returned to the medication cart with the same gloves, removed the gloves, and put on a new pair without performing hand hygiene before cleaning the glucometer and preparing to give insulin. The LPN stated he or she had not realized hand hygiene was missed between glove changes and said it should have been done before giving insulin. Another LPN and the DON stated staff should perform hand hygiene between glove changes and that staff received regular hand hygiene training. The facility further failed to ensure shared medical equipment was cleaned before and after use for a resident who required blood pressure monitoring before receiving antihypertensive medications. The resident had diagnoses including dementia, atrial fibrillation, hypertension, and heart failure. During medication pass, a CMT performed hand hygiene, entered the resident’s room, used a blood pressure cuff without sanitizing it first, obtained the blood pressure, administered medications, and did not sanitize the cuff after use. The CMT stated the cuff was used on multiple residents during medication pass and should have been cleaned before and after each use. The DON stated shared medical equipment should be cleaned before and after use.
Unsupervised Medications Left at Bedside Despite No Self-Administration Approval
Penalty
Summary
The facility failed to ensure that only residents assessed and determined safe by the interdisciplinary team (IDT) could self-administer medications, and it failed to ensure medications were not left unattended for a resident who had been assessed as unable to self-administer. The cited resident had multiple diagnoses including cerebral infarction, dysphagia, congestive heart failure, atrial fibrillation, pulmonary hypertension, chronic kidney disease, and COPD. The resident’s quarterly MDS showed the resident was cognitively intact and able to understand others and make needs known. The resident’s Medication Self-Administration Safety Screen showed the resident was assessed for self-administration of all medications and was determined to require assistance with reading labels, identifying medications, stating what each medication was for, stating the time/frequency, and stating the correct dosage and quantity. The assessment indicated all medications were to remain with staff and that the IDT determined it was not safe for the resident to self-administer any medications. The resident’s physician order sheet and MAR listed multiple scheduled medications, and there was no physician order for self-administration or for keeping medications at bedside. Despite this, surveyors observed an expired Vitamin D3 bottle with unidentified pills in it on the resident’s bedside table, an open bag of cough drops on the bedside table, and a small plastic cup filled with medications on the bedside table. During interviews, the resident stated the pills were for strength and that he/she administered them daily, and also stated the medications had been given that morning but he/she was not ready to take them yet. A CMT stated he/she gave the resident all morning medications and watched them be swallowed, but was not aware of any medications kept in the room or where to find the self-administration assessment. The DON stated residents determined ineligible for self-administration should not have medications left with them or kept at bedside, and that staff should ensure all medications were taken and swallowed before leaving the room.
Failure to Submit TPL Form After Resident Death
Penalty
Summary
The facility failed to submit a Third Party Liability (TPL) form to Missouri HealthNet within 30 days after the death of one resident. Resident #11 died with a resident trust account balance of $8.68, and review of the trust fund records 49 days after the death showed that no TPL had been submitted within the required timeframe. During interview, the Business Office Manager stated that the TPL was not submitted because he/she believed the guardian was responsible for submitting the TPL forms.
Failure to Follow Criminal Background Check Policy
Penalty
Summary
The facility failed to follow its Abuse and Neglect policy and procedure for checking criminal background information for two sampled employees, Maintenance Worker A and CNA C, out of 10 sampled employees. The policy stated the facility maintains a zero-tolerance program for abuse, neglect, mistreatment, and misappropriation of resident property, and that it does not knowingly employ anyone with certain abuse-related findings or convictions. The facility census was 59 residents. Maintenance Worker A’s record showed a hire date of 7/1/23, but the criminal background check was not requested until 8/19/24 and was received the same day. CNA C’s record showed a hire date of 1/6/25, but the criminal background check was requested on 9/18/24 and received the same day. During interview, the Human Resources Director stated Maintenance Worker A was not a re-hire and that the original criminal background check could not be found. The Human Resources Director also stated CNA C was rehired on 1/6/25 and the former Human Resource Director did not re-run the background check as required.
Incomplete Fall Investigation and Notification Documentation
Penalty
Summary
The facility failed to complete a comprehensive investigation after a resident fell from a chair and sustained a minor injury. The resident had multiple diagnoses including heart failure, depression, anxiety, arthritis, auditory and visual hallucinations, dementia, and muscle weakness. The resident’s MDS showed significant cognitive incapacity and need for supervision with transfers and mobility, and the care plan identified the resident as being at risk for falls related to confusion. According to the nursing notes and incident report, the resident was found lying face down on the floor after an unwitnessed fall from a chair while asleep and leaning forward. The resident had an abrasion to the forehead and bridge of the nose, and staff assisted the resident back into the chair using a gait belt. The documentation did not consistently describe the circumstances of the fall, including where the resident was located, when the resident was last seen, what the resident was doing immediately before the fall, or a detailed description of the abrasion. The incident report also did not identify contributing environmental, physiological, or situational factors, and it did not show that the resident was not wearing grips on the socks. The record also did not show notification of the resident’s family or emergency contact after the fall, despite the resident’s confusion and inability to make decisions independently. Staff documented the resident as his or her own responsible party, while the DON stated the resident had a BIMS of 3 and was not believed to be able to make his or her own decisions. The facility’s fall documentation was incomplete in that it did not include a comprehensive risk analysis of what occurred and did not clearly document all required notifications and investigation details.
Missing Order and Care Plan for Self-Performed Ostomy Care
Penalty
Summary
The facility failed to obtain a physician’s order and failed to update the care plan for a resident with a colostomy and urostomy who was providing his/her own ostomy care. The resident was admitted with paraplegia, colostomy status, neuromuscular dysfunction of the bladder, and artificial opening of the urinary tract status. The resident’s nursing self-medication assessment stated the resident could not self-administer medication and required nursing staff to administer medications, and there was no nursing assessment in the record to evaluate the resident’s ability and knowledge to provide own self-care for the colostomy and urostomy. The resident’s care plan addressed ADL self-care deficits related to paraplegia, but it did not include the resident’s ability to provide own self-care for the colostomy or urostomy. The physician order sheet and TAR contained orders for nursing to provide and change the urostomy and colostomy appliances, monitor the stomas, and change bags as needed, but there was no physician’s order allowing the resident to provide own ostomy care or to assist with ostomy care. The record also did not contain a documented self-care assessment for ostomy care, despite staff stating the resident had been providing most of his/her own ostomy care with standby assistance. During interviews, the resident stated he/she provided his/her own colostomy and urostomy care and had shown staff how to change the bags. The DON, LPN, ADON, and ICP acknowledged that the resident had been providing his/her own ostomy care, that there was no physician’s order for self-care, and that a self-care assessment should have been completed and documented. Observation showed the resident’s urostomy and colostomy sites were pink with no redness or signs of infection, and the resident reported no concerns with ostomy care.
Incorrect Tube Feeding Formula and Incomplete Care Plan Documentation
Penalty
Summary
The facility failed to ensure the physician-ordered enteral supplemental tube feeding formula was followed for one resident with a gastrostomy tube and failed to update the resident’s care plan to include the prescribed tube feeding formula. The resident was admitted with gastrostomy status and dysphagia, was severely cognitively impaired, and required supplemental tube feeding for nutritional intake. The care plan documented the need for tube feeding, but it did not identify the type of formula prescribed by the physician or registered dietitian. The resident’s physician order sheet listed Fiber Source HN 1.2 via PEG tube at 47 ml/hour continuously for 22 hours, with a possible two-hour break in 24 hours for activities and care. The treatment administration record also reflected Fiber Source HN 1.2. However, during observation, the resident’s tube feeding pump was running with Diabetisource AC 1.2 cal instead of the ordered formula, and the bag was labeled with handwritten dates. Nursing documentation noted the resident remained NPO with continuous PEG-tube feedings, but did not identify the formula being administered. On a later observation, Diabetisource AC was again connected and running at 47 ml/hour, even though Fiber Source HN 1.2 had been transcribed to the physician order sheet. During medication administration via the PEG tube, the LPN placed the tube feeding on hold, disconnected it, and then reconnected the Diabetisource AC after medications were given. The LPN stated the physician order showed Fiber Source HN and not Diabetisource AC. The DON stated staff were expected to check the physician order and double-check before connecting the tube feeding, and also stated the resident’s care plan had been reviewed and updated during IDT meetings.
Uncovered oxygen equipment and tubing
Penalty
Summary
The facility failed to ensure respiratory face masks and tubing were covered to prevent cross contamination when not in use for two residents. The facility policy stated that oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen were for single resident use only and were to be stored in a plastic bag at the resident’s bedside when not in use. One resident had diagnoses that included COPD, heart disease, respiratory failure, chronic cough, and rhinitis, and was dependent on staff for multiple activities of daily living and used oxygen. The resident’s record showed continuous oxygen at 2 liters, daily humidifier checks, and CPAP use for COPD. During observations, the resident was in bed or sitting up with oxygen in place, while the CPAP machine and breathing treatment machine were on the dresser with the face masks and tubing uncovered and lying on top of or beside the machines. The resident stated that the breathing treatment machine was used during the day and the CPAP machine at night, and staff assisted with both machines. The second resident had COPD, nicotine dependence, smoked, and received oxygen therapy. The resident’s record included orders for oxygen via nasal cannula as needed and weekly disposal of oxygen tubing, humidifier, and plastic bag if present. During three observations, the nasal cannula and tubing connected to the oxygen concentrator were on the floor under clothing items, were not bagged, and were dated 2/6/26; the water container was not dated. Staff interviews confirmed that oxygen tubing, cannulas, masks, and water containers should be changed weekly, dated, and kept off the floor and bagged when not in use, and the DON stated nursing staff were responsible for ensuring this was done.
Cold Food Served Above Safe Temperature
Penalty
Summary
The facility failed to ensure a cold dish, cottage cheese fruit plate, was served at a temperature at or close to 41 F to three residents who received room trays on the 100 Hall. The recipe for the dish identified a critical control point to hold the food for service at 41 F or lower, and the preparation instructions stated that ingredients should be returned to refrigerator storage if preparation was interrupted. On 2/23/25 at 11:53 A.M., a Dietary Aide placed bowls of cottage cheese fruit plate on room tray carts. From 11:53 A.M. to 12:19 P.M., the plates remained on the cart without being returned to refrigeration. The room trays arrived on the 100 Hall at 12:20 P.M., and a CNA delivered trays to the 100 and 200 Halls from 12:21 P.M. to 12:30 P.M. At 12:31 P.M., in the presence of the DON and CNA, the temperature of the cottage cheese fruit plate was measured at 52.1 F. During interview, the Dietary Manager stated there were times temperatures of room trays were checked, but he/she could not check them that day because he/she was the cook and did not have time, and said the cottage cheese fruit plates probably got warmer because they were on the same cart with the hot foods.
Pureed Chicken Was Served With an Improper Texture
Penalty
Summary
The facility failed to ensure that pureed chicken tenders were prepared in a smooth consistency for residents on pureed diets. The undated recipe for pureed baked chicken called for baked chicken, chicken base with water, and commercial thickener. During observation, the Dietary Manager made pureed chicken and added broth but did not add thickener, and there was no recipe book open while the food was being prepared. After the chicken was placed in a pan, the Dietary Manager did not taste it. The state surveyor later tasted the pureed chicken and found that it was grainy rather than smooth, although it was flavorful. When the Dietary Manager tasted it after being asked by the surveyor, he/she acknowledged that it was grainier than it should have been and stated that if it had been tasted the first time, the texture problem would have been identified.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who was sent to the hospital and subsequently discharged with paperwork indicating a return to a homeless shelter. The resident, who was cognitively intact and had a history of diabetes and traumatic brain injury, had expressed a desire to remain in long-term care according to their care plan. Despite this, the discharge paperwork listed a homeless shelter as the destination, and the discharge was marked as immediate due to the resident being considered a danger to self and others, with the notice lacking the resident's signature. Interviews with facility staff revealed a lack of clarity and documentation regarding the discharge process. The Social Services Director stated the resident did not request discharge, and the DON was unaware if the discharge packet was completed or if discharging to a homeless shelter was appropriate. The Administrator confirmed that the resident was told not to return to the facility and that the discharge was considered immediate, citing behavioral concerns such as inappropriate comments and alcohol use. However, there was no documentation of significant behavioral incidents in the medical record, aside from a single report of inappropriate comments. The facility was unable to provide a discharge policy when requested, and staff interviews indicated uncertainty about proper discharge procedures and documentation. The discharge notice was delivered to the hospital along with the resident's belongings, but the process lacked clear documentation and did not include the resident's agreement or signature. The actions taken did not align with the resident's expressed wishes or ensure a safe and appropriate discharge destination.
Failure to Inform Residents of Therapy Procedures Leads to Discomfort
Penalty
Summary
Contracted Physical Therapy Assistant (PTA) A failed to adhere to residents' rights by not adequately informing residents about the care and treatments being provided prior to initiating therapy sessions. Multiple residents reported that PTA A did not explain the procedures or the reasons for physical contact during therapy, such as muscle palpation or massage-like actions. This lack of communication led to confusion and discomfort among several residents, some of whom were unfamiliar with therapy or had not previously received such treatments from PTA A. The deficiency involved seven residents, most of whom were cognitively intact and had various medical conditions including post-surgical weakness, stroke, muscle wasting, and spondylosis. Residents described instances where PTA A entered their rooms, began therapy or massage-like activities without prior explanation, and in some cases, touched areas near the chest or abdomen. While no residents reported pain or physical injury, several expressed feeling uncomfortable, nervous, or "creepy" after the interactions. Some residents did not immediately report the incidents, only disclosing their discomfort when later questioned by facility staff. Interviews with facility staff and the contract therapy agency director confirmed that proper protocol required PTA A to explain all procedures and obtain informed consent before touching residents, especially in sensitive areas. The director acknowledged that certain therapy techniques might require contact with the chest or inner thigh, but emphasized the necessity of clear communication to prevent misunderstanding. The lack of explanation and failure to ensure residents understood the nature of the therapy led to the deficiency, as residents' rights to be informed and to refuse care were not upheld.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the care plans for several residents were updated to reflect their current medical conditions and needs. Resident #29's care plan did not include information about an unstageable pressure ulcer, despite the resident having a physician's order for wound care treatment and a documented risk for pressure ulcers. The MDS Coordinator confirmed that the resident should have had a care plan for any type of wound, indicating a lapse in updating the care plan to reflect the resident's current condition. Resident #18's care plan was not updated to reflect the resident's need for assistance and supervision while smoking. Despite assessments indicating the resident required supervision, observations showed the resident smoking without proper assistance, leading to unsafe situations where other residents had to help. Interviews with staff revealed inconsistencies in the supervision and assistance provided to the resident, highlighting a failure to ensure the care plan accurately reflected the resident's needs and the facility's policies. Resident #38's care plan lacked documentation related to the resident's current pain status, including frequency, type, and location of pain, as well as non-pharmacological pain interventions. The resident had multiple orders for pain medications and reported constant pain that affected daily activities. Similarly, Resident #47's care plan did not document all pressure ulcers, missing information about a pressure ulcer on the right heel. The DON confirmed that care plans should be updated quarterly and as needed, indicating a failure in the facility's process for maintaining accurate and comprehensive care plans.
Failure to Properly Screen for Tuberculosis
Penalty
Summary
The facility failed to ensure proper screening for Tuberculosis (TB) for both residents and new employees. Four residents were not screened according to the facility's TB policy, which mandates a two-step TB test upon admission and annual testing thereafter. For instance, Resident #29 had multiple instances where TB tests were either not read or not documented, and similar issues were observed with Residents #38, #47, and #50. The Infection Preventionist (IP) and Director of Nursing (DON) acknowledged that many residents' TB tests were not done timely or documented correctly, attributing the lapses to previous staff not keeping track of the tests properly. Additionally, the facility failed to properly screen new employees for TB before they started working. Employee G and Employee J did not have their TB tests completed and documented as required. Employee G's second TB test was administered but not read, while Employee J started working before the first TB test was administered. The Assistant Director of Nursing (ADON) and the Business Office Manager (BOM)/Human Resources (HR) Director confirmed these lapses, with the ADON admitting that new employees were usually hired directly after the interview and started working once the first TB test was read with a negative result. Interviews with the IP, DON, ADON, and BOM/HR Director revealed systemic issues in the administration and documentation of TB tests for both residents and employees. The IP and DON were responsible for ensuring timely TB tests for residents, while the ADON was responsible for tracking employee TB tests. However, the lack of proper documentation and adherence to protocols led to significant deficiencies in the facility's infection prevention and control program.
Failure to Provide Required CNA Training
Penalty
Summary
The facility failed to provide the required 12 hours of training and in-services, including behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The review of the training records for these CNAs showed that they did not receive the necessary training in critical areas such as abuse and neglect, behavior and dementia training, resident rights, and care of cognitively impaired residents. Despite attending various in-services, the specific required topics were not covered, and the total training hours did not meet the mandated 12 hours from April 2023 to April 2024. During an interview, the Director of Nursing (DON) confirmed that CNAs should receive 12 hours of in-service training annually, with monthly in-services covering essential topics like abuse and neglect safety, dementia and Alzheimer's safety, and other resident needs. The DON also mentioned that in-services were typically an hour long and conducted by the DON, ADON, or other department heads. However, the facility failed to provide documentation of a policy for the required training, and the Human Resource staff did not adequately monitor the in-service hours for the CNAs, including those working on a PRN basis.
Failure to Develop Spend-Down Plan for Resident Trust Funds
Penalty
Summary
The facility failed to develop a spend-down plan for two residents who maintained a balance exceeding the Missouri Medicaid limit of $5,726.00 in their Resident Trust Fund (RTF) accounts for more than one month. Resident #13's RTF balance consistently exceeded the legal limit from September 2023 to March 2024, reaching as high as $11,044.75. Similarly, Resident #18's RTF balance also remained above the legal limit during the same period, with a peak balance of $10,944.75. Despite these excessive balances, the facility did not take appropriate action to assist the residents in managing their funds to avoid losing Medicaid benefits. During an interview, the Business Office Manager (BOM) acknowledged responsibility for the RTF accounts and admitted to informing the residents that their balances were over the legal limit. However, the BOM did not inform the residents of the potential loss of Medicaid benefits due to the excess funds, nor did they assist in creating a plan to spend down the RTF money. The BOM's approach was limited to advising the residents to spend their money without providing further guidance or support, leading to the deficiency in managing the residents' funds effectively.
Failure to Accurately Document Resident's Advance Directives
Penalty
Summary
The facility failed to properly and accurately document a resident's advance directives, resulting in conflicting information regarding the resident's code status. The resident, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), chronic kidney disease, and major depressive disorder, had both a Do Not Resuscitate (DNR) order and a Full Code order documented in their care plan. This discrepancy was found during a review of the resident's electronic health record (EHR) and care plan, which showed conflicting information about the resident's wishes for life-saving measures. Interviews with facility staff, including a Certified Nurse's Assistant (CNA), a Registered Nurse (RN), the MDS coordinator, and the Director of Nursing (DON), revealed a lack of clarity and consistency in documenting and updating the resident's code status. The resident's guardian had provided verbal consent for Full Code, but the care plan still contained both Full Code and DNR orders. The MDS coordinator acknowledged the error and stated that the care plan would be revised immediately. The DON confirmed that the code status should be clearly documented and consistent across all records, and that the resident's wishes should be accurately reflected in the care plan and physician orders.
Failure to Conduct Timely Background Checks and NA Registry Checks for New Employees
Penalty
Summary
The facility failed to follow its policy to conduct Criminal Background Checks (CBC) and check the Nurses Aide (NA) Registry for new employees before hiring. Specifically, the facility did not complete a NA registry check for Employee B before their hire date and completed the NA registry check for Employee F two days after their hire date. The Business Office Manager (BOM)/Human Resources (HR) admitted that sometimes background checks slipped through the cracks, and employees were not supposed to start working until all background screenings, including NA Registry checks, were completed. Despite having a checklist to ensure all backgrounds were completed before employees started working, the facility allowed Employee B to start work immediately without completing the background process, and Employee F started working before their NA registry check was completed. During interviews, the BOM/HR and the Director of Nursing (DON) confirmed that the NA registry check should be completed before new employees start working. The BOM/HR was responsible for completing the NA registry and background checks for new hires. The facility's failure to adhere to its policy resulted in two employees starting work without the necessary background checks, which is a deficiency in the facility's hiring process and compliance with regulatory requirements.
Failure to Provide Necessary ROM Treatment and Services
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain and improve the range of motion (ROM) and mobility for a resident with significant medical conditions. The resident, who had a history of cerebral infarction, hemiplegia, and muscle weakness, was observed to have a contracted left hand without any devices or equipment to maintain a neutral hand position. Despite having an order for a left arm splint from a previous facility, the splint was never provided, and the resident did not receive any physical or occupational therapy or restorative therapies during the assessment period. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) revealed that the resident was not on therapy services and had not been evaluated or treated by the therapy department upon admission. The DOR acknowledged that the resident would have benefited from a splinting device or restorative therapies to prevent worsening of contractures. The DON confirmed that orders from the previous facility should have been reviewed and continued if appropriate, and that the resident should have received treatment to maintain or improve ROM. The lack of appropriate interventions and equipment led to the resident's continued contractures and limited mobility.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the monthly pharmacy Drug Regimen Review (DRR) recommendations for Resident #29 were reviewed and acted upon by the physician. The pharmacist's notes from 3/22/23, 4/27/23, and 9/1/23 indicated that there were irregularities and recommendations that needed to be addressed. However, no reports or physician responses were found in the resident's medical record for the notes from 3/22/23 and 4/27/23. On 9/1/23, the pharmacist recommended evaluating the necessity of two blood-thinning medications and monitoring for abnormal bleeding or bruising. Although the physician discontinued one of the medications, there was no order to monitor for abnormal bleeding or bruising as recommended by the pharmacist. The facility's policy requires that the physician respond to the pharmacist's recommendations within 30 days, but this was not done for Resident #29's DRR recommendations. Resident #29 had a medical history that included cerebral infarction, hemiplegia and hemiparesis following a stroke, bipolar disorder, anxiety disorder, and major depressive disorder. The DON confirmed that the pharmacist reviewed medications monthly and emailed the recommendations, which were then given to the physician for review and sign-off. The DON also stated that the physician should respond to the pharmacist's recommendations within 30 days and that follow-up would be done if no response was received. Despite these procedures, the facility did not ensure that the physician reviewed and acted upon the pharmacist's recommendations for Resident #29, leading to a deficiency in the resident's care.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that two residents received necessary dental services for broken teeth. Resident #25, who was admitted with moderate protein-calorie malnutrition, had most of their teeth missing or broken and had not seen a dentist since admission. Despite the resident's complaints of pain and requests to see a dentist, no dental appointments were made, and the resident's care plan did not address any dental issues. Observations confirmed the resident's poor dental condition, and interviews with staff revealed a lack of awareness and action regarding the resident's dental needs. Resident #51, admitted with a need for assistance with personal care, also had significant dental issues, including missing and broken teeth. The resident expressed a desire to see a dentist and have their teeth pulled and replaced with dentures. However, similar to Resident #25, no dental appointments were made, and the resident's care plan did not reflect any dental concerns. Staff interviews indicated that there was no proper documentation or follow-up on the resident's dental needs, and the facility's new computer system lacked a place to chart oral care or dental issues. Interviews with various staff members, including the Certified Medication Technician, Assistant Director of Nursing, Certified Nursing Assistant, Social Service Director, and Director of Nursing, highlighted systemic issues in the facility's handling of dental care. There was confusion about responsibilities, inadequate documentation, and a lack of follow-up on residents' dental needs. The facility's policy required regular dental assessments and care, but these were not consistently implemented, leading to the deficiency in providing necessary dental services to the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Butler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Butler | 0.5 mi | ★★★★★ | 15 | 0 |
| Baptist Homes Of Adrian | 9.9 mi | ★★★★★ | 15 | 0 |
| Appleton City Manor | 17.9 mi | ★★★★★ | 2 | 1 |
| Nathan Richard Health Care Center | 27.2 mi | ★★★★★ | 2 | 0 |
| Meadow View Health & Rehabilitation | 27.9 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.