Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Medicalodges Butler during CMS and state inspections, most recent first.
Failure to maintain negative airflow was observed in the South Hall soiled utility room and in resident rooms 132, 130, and 128. Surveyors used a tissue test at the ceiling vents and found no negative airflow in each area. The issue potentially affected at least 10 residents on the [NAME] Short Hall and South Hall, and the Maintenance Supervisor stated he/she had not had a chance to check airflow in all rooms during the prior 3 weeks.
Pest Control and Attic Maintenance Deficiency: The facility failed to keep attic areas above two halls free from openings and animal droppings. During observation with the Maintenance Supervisor, openings were seen in the attic walls above the short [NAME] Hall and South Hall, along with numerous squirrel droppings. The Administrator stated the attic areas had been checked monthly when the previous maintenance person was employed and that a special vacuum cleaner was used to clean the droppings.
Failure to invite cognitively intact residents to their own care plan meetings. Two residents were not invited, with staff instead relying on family invitations or separate discussions. One resident had significant assistance needs and said he/she could not remember being invited, while the other said he/she wanted to attend and be more involved in care decisions. The SSD, CNA, RN, and DON all acknowledged that residents who are cognitively able should be invited in writing and participate in their own care planning.
Unresolved grievance regarding missing resident clothing: A cognitively intact resident and family reported missing gowns, dusters, and an undergarment, but the SSD’s review, laundry follow-up, and closet inventory did not lead to a timely resolution. The resident later stated the grievance had never been resolved, while the SSD, DON, RN, and CNA interviews showed uncertainty about the grievance process and acknowledged the missing items should have been resolved or replaced by that point.
Failure to notify the Ombudsman of a planned discharge. A resident admitted for skilled nursing after a fall with a fractured hip was discharged home, alert and oriented, and able to make decisions. The facility did not provide documentation of Ombudsman notification, and the Administrator stated the Ombudsman was not notified because the discharge was planned; the DON said he/she would have expected the Ombudsman to be notified because that was the regulation.
A resident with a cardiac pacemaker was not identified in the care plan, and the facility had no policy for pacemakers or other IMDs. The resident’s hospital referral, EMR, and nurse admission assessment all documented the pacemaker, but the care plan initially omitted it. The Care Plan Coordinator later added pacemaker-related details, while the DON stated the facility did not use physician orders to direct pacemaker care and only addressed these devices on care plans.
A resident with dementia, DM II, and CKD experienced significant weight loss, dropping from 209 lbs. to 182.4 lbs. over three months. The RD recommended a sugar free house supplement BID after documenting 5% weight loss in one month and 8% in three months, but the order was never placed and the supplement intervention remained blank in DON weight notes. Observations showed the resident received breakfast without a supplement, and interviews confirmed the family was not informed, the RD was not told the recommendation was not being followed, and the DON acknowledged the recommendation was not documented as reviewed even though NP disagreed with it.
An LPN administered 10 units of Humalog insulin instead of the prescribed 10 units of Lantus to a resident with Type II Diabetes Mellitus, after failing to verify the medication against the MAR and not checking the insulin pen from the emergency kit. The error was discovered hours later when the resident's blood sugar was found to be critically low, prompting immediate intervention.
The facility failed to maintain cleanliness and proper maintenance in the kitchen, with food debris and dust buildup under refrigerators, behind the ice machine, and on sprinkler heads. A 9-inch crack was found on the freezer gasket, and debris was present in the dishwasher spray wand. Interviews confirmed lapses in cleaning routines and maintenance.
The facility failed to submit TPL forms to MO Health Net within 30 days of death for three deceased residents and did not submit a check with remaining funds within 5 days of discharge for one resident. The BOM admitted to delays and lack of awareness of regulatory requirements, affecting four discharged residents.
The facility failed to ensure negative airflow in the soiled utility room and restrooms of multiple resident rooms, potentially affecting at least 20 residents. Observations and interviews revealed that switches controlling the negative air flow vents were either turned off or not working, leading to the deficiency.
The facility failed to maintain the East hall attic area free of openings and debris indicating pests, the South hall attic area free of hay/straw, and the dementia unit attic free of animal droppings and feathers. The Maintenance Director confirmed these issues during a survey and admitted to limited access during monthly inspections. These deficiencies potentially affected 40 residents, with a facility census of 70.
The facility failed to update care plans and implement interventions for two residents, leading to falls and injuries. One resident, with a history of hemiplegia, fell and fractured bones due to not wearing a knee brace during a transfer. Another resident with Alzheimer's was left alone in the dining room and fell, resulting in a hematoma. The care plans were not adequately reviewed and revised, and staff did not consistently follow the interventions.
A facility failed to identify, assess, and provide supportive interventions for a resident with PTSD. The care plan did not address the resident's PTSD, including triggers and interventions. Staff were unaware of the resident's PTSD diagnosis, and the MDS Coordinator acknowledged the care plan's deficiencies. The DON confirmed the expectation for complete care plans and staff awareness, but the care plan was found to be inadequate.
Failure to Maintain Negative Airflow in Soiled Utility Room and Resident Rooms
Penalty
Summary
The facility failed to maintain required negative airflow in the South Hall Soiled Utility Room and in resident rooms 132, 130, and 128. Surveyors observed that at 11:53 A.M. there was no negative airflow in the South side soiled utility room, and at 1:13 P.M., 1:21 P.M., and 1:27 P.M. there was no negative airflow in resident rooms 132, 130, and 128, respectively. Air flow was tested by holding a piece of tissue paper to the ceiling vent, with negative airflow indicated when the paper was drawn to the vent and absent when the paper fell. The deficiency potentially affected at least 10 residents on the [NAME] Short Hall where the soiled utility room was located and residents on the South Hall. During interview, the Maintenance Supervisor stated he/she had not had a chance to check for negative airflow in all the rooms in the 3 weeks he/she had been at the facility.
Pest Control and Attic Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the attic areas over the short [NAME] Hall and the South Hall free from openings that could allow pests into the attic areas, and failed to keep those attic areas free from numerous animal droppings. During observation with the Maintenance Supervisor, a 15-inch long by 1-inch wide opening was seen along the outer wall of the attic above the short [NAME] Hall, along with numerous animal droppings in that area. A separate observation showed a 15-inch long by 3-inch wide opening on the outer wall of the attic above the South Hall, also with numerous animal droppings. During interview, the Administrator stated the attic areas had been checked monthly when the previous maintenance person was employed, that the facility had a special vacuum cleaner used to vacuum-clean the droppings, and that the droppings in the photograph were squirrel droppings.
Failure to Invite Cognitively Intact Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite two cognitively intact residents to their care plan meetings and instead relied on family participation or separate staff-resident discussions. For Resident #7, the record showed the resident was admitted to the facility and had care needs including partial to maximum assistance with transfers and dressing, partial assistance with ambulation, fall risk, assistance with toileting and daily routines, and monitoring for medication side effects. The quarterly MDS showed the resident was cognitively intact and required varying levels of assistance with personal care, bathing, dressing, transfers, ambulation, and toileting. During interview, the resident said he/she could not remember being invited to a care plan meeting, and no care plan invitation was provided for review. Staff interviews showed the Social Services Designee met with Resident #7 a week before the care plan meeting and believed that discussion was enough, while family was invited but the resident was not. CNA and RN staff said they had not seen the resident attend care plan meetings, and the DON stated all residents should have been invited in writing and allowed to attend so they would feel empowered and know what care to expect. The facility did not provide a policy for care plan meetings when requested. For Resident #55, the quarterly MDS showed the resident was cognitively intact. The care plan meeting form showed the resident's family had been invited to the meeting and not the resident. The resident stated he/she had not been invited to care plan meetings and wanted to attend and be more involved in care decisions. The SSD said the resident's son had typically been invited and that the resident was his/her own person and able to fully participate, while the resident's care plan meeting form for the quarterly meeting had not been completed in the EMR. Staff interviews, including CNA, RN, and DON, confirmed that cognitively able residents should be invited to their own care plan meetings and that written invitations were needed.
Unresolved grievance regarding missing resident clothing
Penalty
Summary
The facility failed to ensure prompt resolution of a grievance filed by a cognitively intact resident regarding missing personal clothing items. The resident’s sons reported that two gowns, two dusters, and an undergarment were missing, while the resident identified several specific gowns, dusters, and an undergarment as missing. An inventory of the resident’s closet found seven gowns, three dusters, and multiple undergarments, and the resident stated that three gowns and three dusters had been soiled and sent to laundry over the prior two days. The Social Services Designee (SSD) followed up with laundry, which said it was already aware of the missing items but could not locate them, and the SSD emailed the family the resident’s closet inventory. The grievance remained unresolved for weeks after it was filed. The family was told on 7/28/25 that the facility would continue looking for the missing items and would assist the resident in selecting new items if they could not be found, and an email stated the SSD would involve the Administrator if the items were still missing in the next couple of weeks. During later interviews, the resident said the grievance had never been resolved and was unsure whether replacement of the items was the resolution. The SSD stated the grievance had not been resolved and that the facility was still waiting for laundry to cycle through to see if the items could be found. The DON, RN, and CNA interviewed were unsure of the grievance process or stated that the missing items should have been replaced by that point, and the DON said a resolution should have been found by then.
Failure to Notify Ombudsman of Planned Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a planned discharge for one resident. Resident #77 was admitted for skilled nursing services after a fall with a fractured hip, and the care plan documented a goal to discharge home. Progress notes later stated the resident was discharged home, was alert and oriented, and was able to make decisions, and the discharge MDS indicated the resident had short-term memory that was okay, was independent in making decisions regarding daily life, and had no evidence of acute mental status change or disorganized thinking. During record review, the facility did not provide a copy of Ombudsman notification when requested. In interview, the Administrator stated the discharge was planned and he/she did not think the Ombudsman needed to be notified, and also stated he/she did not notify the Ombudsman. The Administrator said the SOM being used was dated 8/4/2024 and did not know the current SOM was dated 7/23/25. The DON stated he/she did not do the notifications to the Ombudsman and would have expected all Ombudsmen to have been notified because that was the regulation.
Pacemaker Care Not Identified or Directed
Penalty
Summary
The facility failed to identify and direct the care of a resident with a cardiac pacemaker and failed to develop a policy to direct staff responsibilities for residents with pacemakers and/or implanted medical devices. Resident #38’s hospital referral information showed a past surgical history of pacemaker implantation, and the resident’s EMR listed a diagnosis of presence of cardiac pacemaker. The licensed nurse’s admission assessment also documented that the resident had a cardiac pacemaker, but the resident’s care plan did not mention the pacemaker or include interventions for it. During interview, the Care Plan Coordinator said admission paperwork was reviewed for all residents and that this was normally how a pacemaker would be identified, but the resident’s pacemaker had been missed until the evening before the interview. The Care Plan Coordinator later added care plan interventions stating the resident had a biventricular pacemaker, had a continuous monitoring device in the room, had a remote pacemaker check on July 17, 2025, and included the cardiologist’s name and contact information. The DON stated the facility did not have a policy addressing pacemakers or other IMDs, did not obtain physician orders directing pacemaker care, and addressed pacemakers only on care plans rather than in physician orders. The DON also stated resident admission records only included the primary care physician and did not include cardiologists or other relevant specialists.
Failure to Follow RD Supplement Recommendation for Weight Loss
Penalty
Summary
The facility failed to follow an RD supplement recommendation for a resident with unspecified dementia, DM II, hypertensive heart disease, and CKD. The resident had severely impaired cognition, was on a therapeutic diet, and had been admitted on a regular diet with pureed texture, thin consistency, diabetic and sodium precautions. The resident’s weight history showed a decline from 209 lbs. on 6/4/25 to 182.4 lbs. on 9/1/25, which was a 12.73 percent loss in three months. On 8/15/25, the RD documented that the resident had lost 5 percent in one month and 8 percent in three months, noted the recent change to a pureed diet, and recommended a sugar free house supplement two times a day to aid in weight maintenance. The DON’s weight progress notes on 8/15/25, 8/20/25, 8/26/25, and 9/2/25 documented the resident’s weight, meal intake, snacks offered three times daily, diuretic and diabetes medication use, and bilateral lower extremity edema, but the supplement intervention sections were blank and there was no documentation that the RD recommendation had been implemented. The resident’s order summary in August and September 2025 did not show any supplement order. Observations on 9/5/25 showed the resident receiving breakfast without a supplement on the tray and later eating 100 percent of breakfast and requesting a second portion, still without a dietary supplement. Interviews with the family member, RN, DON, Administrator, ADON, NP, RD, and another RN showed that the facility had not informed the family of the RD recommendation, the supplement had not been ordered, staff were unsure who had received supplements, and the DON acknowledged the recommendation should have been documented as reviewed even though NP A disagreed with it. The RD stated he/she was unaware the supplement had not been ordered and had not been told the facility disagreed with the recommendation.
Failure to Administer Correct Insulin Resulting in Significant Medication Error
Penalty
Summary
A medication administration error occurred when an LPN administered 10 units of Humalog insulin to a resident instead of the prescribed 10 units of Lantus insulin at bedtime. The LPN obtained the insulin from the emergency kit after noticing the resident was out of Lantus, but failed to verify the medication against the resident's Medication Administration Record (MAR) and did not check the insulin pen to ensure it was the correct drug. This action was not in accordance with the facility's policy, which requires verification of medication orders and the medication itself at multiple points prior to administration. The resident involved had a diagnosis of Type II Diabetes Mellitus and was cognitively intact, with orders for regular blood glucose monitoring and specific insulin regimens: Lantus at bedtime and Novolog three times daily. On the day of the incident, the resident's blood sugar readings were within normal limits prior to the error. After the incorrect administration of Humalog, the LPN discovered the error several hours later while reviewing paperwork, prompting immediate assessment of the resident's blood sugar, which was found to be critically low. The LPN did not follow the established rights of medication administration, specifically failing to confirm the correct medication and dosage before administration. The error was self-identified by the LPN, who then notified the appropriate clinical staff and initiated measures to address the resident's hypoglycemia. The incident was documented in the facility's records, and interviews confirmed that the LPN did not adhere to the required medication administration procedures, leading to the significant medication error.
Kitchen Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in the kitchen area, which potentially affected all residents. Observations revealed a buildup of food debris and dust under the reach-in refrigerators, behind the ice-making machine, and on the sprinkler heads and pipes over the 3-compartment sink and automated toaster. Additionally, a 9-inch crack was found on the gasket of the white upright freezer. These issues were noted during an initial kitchen tour and subsequent observations, indicating a lack of regular cleaning and maintenance routines. Interviews with the Dietary Manager (DM) and Dietary Aides (DA) confirmed the deficiencies. The DM admitted to notifying the Maintenance Assistant about the need for cleaning three weeks prior but had not noticed the damaged gasket on the freezer. The DM also acknowledged that the spray wands of the automated dishwasher, which were supposed to be cleaned nightly, still had debris. The DA responsible for washing dishes did not notice the debris in the dishwasher spray wand. These lapses in cleanliness and maintenance practices were observed over multiple days, highlighting ongoing issues in the facility's kitchen management.
Failure to Submit TPL Forms and Resident Funds Timely
Penalty
Summary
The facility failed to ensure that Third Party Liability (TPL) forms were completed and submitted to MO Health Net within 30 days of death for three deceased residents and failed to ensure a check with the remaining funds was submitted within 5 days of discharge for one discharged resident. Specifically, Resident #219 passed away with $200.11 in their account, and the TPL form was not submitted within the required 30 days. Resident #220 passed away with $87.30 in their account, and the TPL form was also not submitted within the required timeframe of 30 days. Resident #221 had $498.65 in their account at the time of death, and the TPL form was submitted 70 days after the resident's death. Additionally, Resident #218 was discharged with a balance of $20.00 in their account, and the check for the remaining funds was not submitted within the required 5 days of discharge due to a delay caused by a hair care charge that was known at the time of discharge but not immediately processed. During interviews, the Business Office Manager (BOM) admitted to sending checks to funeral homes and the state but failing to complete and submit the TPL forms within the required 30 days for deceased residents. The BOM also acknowledged the delay in processing the check for the discharged resident due to the hair care charge. The BOM was unaware of the requirement to fill out and submit TPL forms for any resident receiving Medicaid or Medicare, indicating a lack of proper training or understanding of the regulatory requirements. This deficiency potentially affected four discharged residents in a facility with a census of 70 residents.
Failure to Maintain Negative Airflow in Soiled Utility Room and Resident Restrooms
Penalty
Summary
The facility failed to ensure there was negative airflow as required in the soiled utility room close to the South Hall and in the restrooms of multiple resident rooms. This deficiency was identified through observations and interviews conducted on 3/26/24 and 3/27/24. During the inspection, it was observed that there was no negative airflow in the soiled utility room near the south nurse's station and in the restrooms of resident rooms 123, 122, 102, and several shared rooms. The negative airflow was tested by holding a piece of tissue paper to the ceiling vent; the paper was not drawn up, indicating the absence of negative airflow. This issue potentially affected at least 20 residents who resided in or used those areas, with the facility census being 70 residents. During interviews, the Maintenance Director revealed that a switch controlling the negative air flow vents in the North and East areas had been turned off in the attics. Additionally, the switch controlling the ceiling vents in the South side areas, including the soiled utility room and several resident rooms, was no longer working. The Administrator admitted that back in January 2024, during extremely cold weather, they had requested the ceiling vents be turned off to reduce drafts. This action led to the current deficiency in maintaining proper negative airflow in the specified areas.
Pest Control Deficiency in Attic Areas
Penalty
Summary
The facility failed to maintain the East hall attic area free of openings that could let in potential pests and failed to keep the area free of debris indicating evidence of pests. Additionally, the South hall attic area was not maintained free of hay/straw, suggesting the presence of pests, and the attic area over the dementia unit contained animal droppings and feathers, indicating past pest activity. These deficiencies were observed during a survey on 3/26/24, where the Maintenance Director confirmed the presence of two openings in the East attic, a nest, a large amount of hay/straw in the South attic, and straw/hay, feathers, and animal droppings in the dementia unit attic. The Maintenance Director admitted during a phone interview on 4/4/24 that he/she inspected the attic areas once per month but was unable to access all areas, leading to the unnoticed hay/straw towards the outer wall. These issues potentially affected 40 residents who resided in or used those areas, with the facility census being 70 residents.
Failure to Update Care Plans and Implement Interventions
Penalty
Summary
The facility failed to update the intervention for the continued use of a knee brace for one resident and to update the care plan with new interventions as needed. The resident, who had a history of hemiplegia and hemiparesis following a stroke, experienced a fall resulting in fractures due to not wearing the knee brace during a transfer. The CNA assisting the resident did not ensure the knee brace was on before the transfer, which was a requirement according to the resident's care plan. The resident's care plan was not updated with new interventions following the fall, and the resident was subsequently transferred using a mechanical lift due to the injury sustained from the fall. Another resident, who had Alzheimer's disease and a history of falls, was left alone in the dining room and fell, resulting in a hematoma. The resident's care plan included an intervention to not leave the resident unattended in the dining room, which was not followed. The resident was also not wearing proper footwear at the time of the fall, which was another care plan intervention that was not implemented. The CNA on duty admitted to leaving the resident alone in the dining room to attend to other residents, despite knowing the resident should not be left unattended. The facility's failure to update care plans with new interventions and ensure the implementation of existing interventions contributed to the falls and injuries of the two residents. The care plans were not adequately reviewed and revised following fall incidents, and staff did not consistently follow the care plan interventions, leading to preventable accidents and injuries.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's care plan did not address PTSD, including the resident's triggers and interventions. Despite the resident being on an antidepressant medication for PTSD, the care plan lacked specific details on how to manage the condition effectively. Interviews with the resident and staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis, triggers, and necessary interventions. The resident expressed that the facility was not addressing their PTSD, which stemmed from past military service. Staff members, including a Certified Medication Technician (CMT), Certified Nurse's Assistant (CNA), and Registered Nurse (RN), were unaware of the resident's PTSD diagnosis, triggers, or interventions. The MDS Coordinator, responsible for care plan development, acknowledged that the care plan should have included this information but did not. The Director of Nursing (DON) confirmed that it was the MDS Coordinator's responsibility to ensure the care plan accurately reflected the resident's condition, including PTSD triggers and interventions. The DON also stated that the Inter-disciplinary Care Team (IDT) audited the care plans and that it was their expectation that all staff would be aware of a resident's triggers and interventions. However, the care plan for the resident with PTSD was found to be incomplete and inadequate, leading to the deficiency noted in the report.
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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) |
|---|---|---|---|---|
| Butler Rehab And Healthcare Center | 0.5 mi | ★★★★★ | 27 | 0 |
| Baptist Homes Of Adrian | 10.1 mi | ★★★★★ | 15 | 0 |
| Appleton City Manor | 17.3 mi | ★★★★★ | 2 | 1 |
| Nathan Richard Health Care Center | 27.1 mi | ★★★★★ | 2 | 0 |
| Medicalodges Nevada | 28 mi | ★★★★★ | 0 | 0 |
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