Inspection Reports for
Butler Rehab and Healthcare Center
416 SOUTH HIGH ST, BUTLER, MO, 64730-1827
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
55 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure a safe and appropriate discharge of a resident to a homeless shelter, raising concerns about discharge procedures and resident safety.
Complaint Details
The complaint investigation found that the resident was discharged immediately to a homeless shelter without proper discharge documentation or resident consent. The resident was cognitively intact and wished to remain in care. The discharge was due to the resident being considered a danger to self and others. Interviews with facility staff revealed lack of completed discharge packets and uncertainty about appropriateness of discharge destination.
Findings
The facility failed to ensure a safe and appropriate discharge for one resident who was sent to a homeless shelter with discharge paperwork. The resident was cognitively intact, wished to stay in long-term care, and was discharged immediately due to being deemed a danger to self and others. Documentation and discharge protocols were incomplete or missing.
Deficiencies (1)
Failure to ensure a safe and appropriate discharge when the facility sent a resident to a homeless shelter without proper discharge policy or documentation.
Report Facts
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding resident discharge and stated resident did not ask to be discharged. |
| Director of Nursing | Director of Nursing | Interviewed and stated unawareness of completed discharge packet and appropriateness of discharge to homeless shelter. |
| Administrator | Administrator | Interviewed and confirmed resident was immediately discharged and would not be allowed back; stated discharge was due to resident being a danger to others. |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to complaints regarding a contracted Physical Therapy Assistant (PTA A) allegedly not adhering to residents' rights to be informed of care and inappropriate touching during therapy treatments for seven residents.
Complaint Details
The complaint investigation was triggered by allegations that contract PTA A inappropriately touched residents during therapy sessions and failed to explain treatments. Seven residents reported feeling uncomfortable or inappropriate touching, though no injuries were found. Some residents did not report incidents immediately. The facility conducted interviews and investigations, confirming the issues and educating staff.
Findings
The investigation found that contract PTA A did not explain treatments to residents prior to providing care, causing discomfort. Multiple residents reported inappropriate touching or feeling uncomfortable during therapy sessions, though no physical injuries were found. The facility educated staff on resident rights and abuse protocols, and the deficiency was corrected.
Deficiencies (1)
Contracted Physical Therapy Assistant did not explain treatments to residents prior to providing care, violating residents' rights to be informed and causing discomfort.
Report Facts
Residents affected: 7
Facility census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Contract PTA A | Physical Therapy Assistant | Named in multiple findings related to failure to inform residents and inappropriate touching during therapy |
| Social Worker A | Social Worker | Reported allegations to facility Administrator |
| Contract Therapy Agency Director A | Contract Therapy Agency Director | Provided expert opinion on appropriate therapy practices and expectations |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff behavior and resident dignity |
| Facility Administrator | Facility Administrator | Interviewed regarding complaint handling and staff education |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 9
Date: Apr 5, 2024
Visit Reason
The inspection was conducted as an annual survey of Butler Rehab and Healthcare Center to assess compliance with regulatory requirements across multiple areas including resident fund management, advance directives, staff screening, care planning, infection control, and staff training.
Findings
The facility was found deficient in several areas including failure to develop spend down plans for resident funds exceeding legal limits, inaccurate documentation of advance directives, incomplete staff background checks, inadequate care plan updates for pressure ulcers, smoking supervision, pain management, and range of motion, failure to act on pharmacist drug regimen review recommendations, lack of dental services for residents with broken teeth, incomplete tuberculosis screening for residents and employees, and insufficient nurse aide training hours.
Deficiencies (9)
Failed to develop a spend down plan for two residents with resident fund balances exceeding the legal Missouri Medicaid limit.
Failed to properly document a resident's advance directives, showing conflicting full code and DNR status.
Failed to conduct Criminal Background Checks and Nurses Aide Registry checks for new employees prior to hire.
Failed to update care plans to reflect unstageable pressure ulcers, smoking supervision needs, pain status, and pressure ulcer treatments for sampled residents.
Failed to provide treatment or services to maintain or improve range of motion for a resident with hemiplegia and contractures.
Failed to ensure pharmacist drug regimen review recommendations were reviewed and acted upon by the physician for a sampled resident.
Failed to provide dental services for two residents with broken teeth.
Failed to properly screen residents and new employees for tuberculosis according to policy and state regulations.
Failed to provide required 12 hours of training/in-services including behavior and dementia training, abuse and neglect prevention, and resident rights for three Certified Nursing Assistants.
Report Facts
Resident census: 56
Resident fund balance: 11044.75
Resident fund balance: 9441.64
Number of sampled residents: 15
Number of sampled employees: 10
Number of CNA staff reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee B | New employee hired 12/18/23 without completed NA registry check | |
| Employee F | New employee hired 7/17/23 with delayed NA registry check completed after hire date | |
| Employee G | New employee with incomplete documentation of second TB test reading | |
| Employee J | New employee started work before TB test completed | |
| CNA B | Certified Nursing Assistant | Did not receive required 12 hours of training/in-services including abuse, dementia, and resident rights |
| CNA C | Certified Nursing Assistant | Did not receive required training in behavior and dementia, resident rights, and care of cognitively impaired |
| CNA D | Certified Nursing Assistant | Did not receive required training in abuse and neglect, behavior and dementia, resident rights, and care of cognitively impaired |
| Business Office Manager | Business Office Manager / Human Resources Director | Responsible for RTF accounts and employee background checks |
| Director of Nursing | Director of Nursing (DON) | Oversight of care plans, TB testing, and staff training |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Administered and tracked employee TB testing |
| Infection Preventionist | Infection Preventionist (IP) | Responsible for infection control and TB screening oversight |
Inspection Report
Routine
Census: 64
Capacity: 98
Deficiencies: 10
Date: Aug 5, 2022
Visit Reason
Routine inspection of Butler Rehab and Healthcare Center to assess compliance with regulatory requirements including resident rights, care planning, employee background checks, infection control, emergency preparedness, and medication management.
Findings
The facility was found deficient in multiple areas including failure to offer/formulate advanced directives, incomplete Skilled Nursing Facility Advance Beneficiary Notices, inadequate employee background checks and Federal Indicator screenings, incomplete and untimely care plans, inadequate supervision of residents with dysphagia, failure to provide necessary behavioral health care, failure to implement gradual dose reductions of psychotropic medications, incomplete tuberculosis screening for employees, and an incomplete emergency operational preparedness plan.
Deficiencies (10)
Failed to offer/formulate advanced directives for two sampled residents.
Failed to provide completed Skilled Nursing Facility Advance Beneficiary Notice at termination of Medicare Part A benefits for two sampled residents.
Failed to ensure Employee Disqualification List, Criminal Background Checks, and Federal Indicator checks were completed prior to hire for ten sampled employees.
Failed to develop and implement complete care plans addressing smoking, depression, and other needs for sampled residents.
Failed to include residents and their representatives in care planning process and conduct care plan conferences with resident participation.
Failed to ensure adequate supervision while eating and drinking for a resident with dysphagia.
Failed to provide necessary behavioral health care services for a resident exhibiting verbal and physical aggression.
Failed to ensure pharmacist recommendations for gradual dose reductions of psychotropic medications were acted upon timely by physicians for four sampled residents.
Failed to properly screen new employees for tuberculosis with two-step testing prior to and after hire date for five sampled employees.
Failed to develop a comprehensive Emergency Operational Preparedness program including documentation of electrical power supply to critical devices and systems.
Report Facts
Residents affected: 2
Residents affected: 2
Employees affected: 10
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees affected: 5
Residents census: 64
Facility capacity: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee A | Laundry Personnel | Background check and FI check deficiencies |
| Employee B | Licensed Practical Nurse | Background check and FI check deficiencies |
| Employee C | Licensed Practical Nurse | Background check and FI check deficiencies |
| Employee D | Housekeeping Personnel | Background check and FI check deficiencies |
| Employee E | Housekeeping Personnel | Background check and FI check deficiencies |
| Employee F | Certified Nursing Assistant | Background check and FI check deficiencies |
| Employee G | Dietary Personnel | Background check and FI check deficiencies |
| Employee H | Certified Nursing Assistant | Background check and FI check deficiencies |
| Employee I | Registered Nurse | Background check and FI check deficiencies |
| Employee J | Certified Nursing Assistant | Background check and FI check deficiencies |
| Director of Nursing | Director of Nursing | Named in advanced directives, SNFABN, background checks, care planning, medication management, and behavioral health findings |
| Minimum Data Set Coordinator | MDS Coordinator | Named in SNFABN, care planning, and medication management findings |
| Admission Coordinator | Admission Coordinator | Named in advanced directives findings |
| Social Services Designee | Social Services Designee | Named in advanced directives and behavioral health findings |
| Registered Nurse B | Registered Nurse | Named in advanced directives, care planning, and behavioral health findings |
| Certified Nursing Assistant A | Certified Nursing Assistant | Named in care planning and supervision findings |
| Certified Nursing Assistant B | Certified Nursing Assistant | Named in behavioral health findings |
| Certified Nursing Assistant C | Certified Nursing Assistant | Named in supervision and behavioral health findings |
| Plant Operations Director | Plant Operations Director | Named in emergency preparedness findings |
| Administrator | Administrator | Named in emergency preparedness findings |
| Business Office Manager | Business Office Manager | Named in background checks and tuberculosis screening findings |
| Registered Dietician | Registered Dietician | Named in supervision during eating findings |
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in supervision during eating findings |
Inspection Report
Routine
Census: 55
Deficiencies: 16
Date: Nov 21, 2019
Visit Reason
The inspection was a routine regulatory survey of Butler Rehab and Healthcare Center to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, financial management, medication administration and documentation, wound care, infection control, food safety, and facility maintenance. Specific issues included failure to provide dignity bags for catheter privacy, lack of authorization for resident funds, incomplete wound care documentation, improper medication storage and handling, inadequate infection control practices, and maintenance deficiencies in resident rooms and kitchen areas.
Deficiencies (16)
Failure to provide dignity bags for residents' Foley catheter bags and ensure privacy curtains and window blinds were closed during personal care.
Failure to obtain authorization to manage resident funds and failure to maintain accurate financial records for resident accounts.
Failure to ensure accurate and clear documentation of residents' code status and timely physician signatures on Do Not Resuscitate (DNR) orders.
Failure to obtain PASARR Level II screening for a resident identified as needing additional mental health screening.
Failure to obtain physician orders for self-administration of medications and for Port-a-cath dressing changes, and failure to monitor and document dressing changes.
Failure to ensure wound care treatments were ordered, administered, and documented properly, and failure to include wound care in care plans.
Failure to obtain physician orders for suprapubic catheter care and failure to maintain catheter bag placement and care.
Failure to complete comprehensive pain assessments and document pain medication administration including pain intensity and non-pharmacological interventions.
Failure to notify physician of significant resident weight gain and failure to follow dietary recommendations and address resident clothing fit issues.
Failure to document destruction of removed Fentanyl patches by two staff members and failure to verify and account for narcotic medications brought in by residents.
Failure to maintain medication refrigerator temperatures, remove expired medications timely, mark multi-dose vials with opening dates, and maintain narcotic storage and medication return processes.
Failure to maintain food temperatures during meal service and cooling processes according to FDA Food Code standards.
Failure to puree mechanical soft foods properly and lack of available recipes for pureed foods.
Failure to maintain kitchen and food preparation areas clean and in good repair, including dust on suppression system pipes, fan vent covers, light fixtures, food debris on floors, peeling refrigerator door gasket, and damaged utensils.
Failure to follow infection control practices including hand hygiene during wound care, glucometer cleaning, insulin administration, and catheter care; failure to maintain infection control tracking and trending; failure to perform and document tuberculosis testing; and failure to maintain isolation precautions properly.
Failure to maintain commode risers, shower chair backing, and resident room furniture in good repair.
Report Facts
Residents affected: 55
Weight gain: 57.6
Weight gain: 37.6
Weight gain: 15
Weight loss: 20
Pressure sore measurement: 3
Pressure sore measurement: 1.5
Pressure sore measurement: 0.2
Pressure sore measurement: 2.3
Pressure sore measurement: 1
Pressure sore measurement: 0
Pressure sore measurement: 2.3
Pressure sore measurement: 1.4
Pressure sore measurement: 0
Medication refrigerator temperature: 119.6
Medication refrigerator temperature: 129.5
Medication refrigerator temperature: 153.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in findings related to catheter care, wound care, medication administration, and infection control |
| LPN C | Licensed Practical Nurse | Named in findings related to catheter care, wound care, medication administration, and infection control |
| CNA C | Certified Nursing Assistant | Named in findings related to catheter care and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in findings related to wound care, medication storage, and infection control |
| Administrator | Administrator | Named in findings related to wound care, medication storage, infection control, and facility maintenance |
| Dietary Manager | Dietary Manager | Named in findings related to food preparation and kitchen maintenance |
| Dietary | Dietary Cook | Named in findings related to food preparation |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in findings related to facility maintenance |
| MDS Coordinator | MDS Coordinator | Named in findings related to financial records and medication management |
| Infection Preventionist | Infection Preventionist | Named in findings related to infection control program and isolation precautions |
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