Inspection Reports for
Butler Rehab and Healthcare Center
416 SOUTH HIGH ST, BUTLER, MO, 64730-1827
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
24.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
56% occupied
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 77
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The document is a Plan of Correction related to a deficiency cited during a facility investigation and inspection regarding resident rights and treatment decisions.
Complaint Details
The visit was complaint-related, triggered by allegations that a contract Physical Therapy Assistant inappropriately touched residents during therapy sessions. Investigations included resident interviews and review of records. The allegations were substantiated based on resident reports and facility findings.
Findings
The facility was found noncompliant with F 552 regarding residents' rights to be informed and make treatment decisions. A contract Physical Therapy Assistant (PTA) failed to fully inform residents and engaged in inappropriate conduct with seven residents, causing discomfort. The facility reviewed policies and conducted interviews and investigations to address the issues.
Deficiencies (1)
F 552 Right to be Informed/Make Treatment Decisions. The resident has the right to be informed of and participate in his or her treatment. A contract Physical Therapy Assistant did not adhere to residents' rights by not explaining treatments and engaged in inappropriate physical contact with seven residents causing discomfort.
Report Facts
Facility census: 77
Number of residents involved: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Contract Physical Therapy Assistant A | Physical Therapy Assistant | Named in multiple findings related to failure to inform residents and inappropriate physical contact |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff maintaining resident dignity and treatment |
| Facility Administrator | Administrator | Notified of noncompliance and interviewed regarding resident complaints and facility response |
| Contract Therapy Agency Director A | Director | Interviewed about appropriate therapy practices and expectations for contract PTA |
| Social Worker A | Social Worker | Reported resident complaints about inappropriate contact by contract PTA |
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 8
Date: Apr 5, 2024
Visit Reason
The inspection was conducted to identify deficiencies and ensure compliance with federal and state regulations at Butler Rehab and Healthcare Center.
Findings
The facility was found deficient in multiple areas including resident trust fund management, advance directives, abuse/neglect policies, comprehensive care planning, infection control, drug regimen review, dental services, and staff screening. The facility failed to meet several regulatory requirements as evidenced by interviews, record reviews, and observations.
Deficiencies (8)
F569 Notice and Conveyance of Personal Funds. The facility failed to develop a spend down plan for two residents who maintained balances exceeding the legal Medicaid limit for more than one month.
F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The facility failed to properly document a resident's advance directives and code status, including CPR and DNR orders.
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to conduct criminal background checks for two new employees prior to hire.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to ensure care plans were updated to reflect pressure ulcers, pain management, smoking assistance, and wound care for sampled residents.
F756 Drug Regimen Review. The facility failed to ensure monthly pharmacist drug regimen reviews were conducted and documented for all residents.
F791 Routine/Emergency Dental Services. The facility failed to ensure residents received routine and emergency dental care, including assessments and appointments.
F880 Infection Prevention & Control. The facility failed to establish and maintain an effective infection prevention and control program, including TB screening and staff training.
F947 Required In-Service Training for Nurse Aides. The facility failed to provide required in-service training for nurse aides, including dementia management and abuse prevention.
Report Facts
Facility census: 56
Resident balances: 5726
Number of sampled residents: 15
Number of new employees reviewed: 10
Number of residents with TB tests reviewed: 15
Number of residents with dental services reviewed: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce A. Leffert | Administrator | Signed plan of correction and report |
| Employee B | New employee without completed NA registry check | |
| Employee F | New employee without completed NA registry check | |
| Employee G | Employee with TB test tracking | |
| Employee J | Employee with TB test tracking |
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
Life Safety
Census: 56
Capacity: 59
Deficiencies: 4
Date: Apr 4, 2024
Visit Reason
A Life Safety Code survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services on 04/04/24 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with smoking regulations and essential electrical system maintenance requirements. Specific deficiencies included failure to provide self-closing ashtrays in smoking areas and lack of battery-powered emergency lighting at the generator transfer switch area.
Deficiencies (4)
K741 Smoking Regulations: The facility failed to ensure the smoking area contained a metal, self-closing container for ashes, affecting 19 residents who smoke. Observations showed missing ash trays and self-closing cigarette butt containers in multiple smoking areas.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the essential electrical system in accordance with NFPA 110 (2010 edition) section 7.3.1, including lack of battery-powered lighting in the generator transfer switch room. This failure had the potential to affect all 56 residents.
A2057 Ashtrays Noncombustibles/Safe/Disposal: Designated smoking areas lacked ashtrays of noncombustible material and safe design, violating 19 CSR 30-85.022(32).
A3030 Electrical Wiring & Equipment Maintained: Electrical wiring and equipment were not maintained in accordance with NFPA 70, 1999 edition, violating 19 CSR 30-85.032(31)(A).
Report Facts
Facility census: 56
Total licensed beds: 59
Residents potentially affected by smoking deficiency: 19
Residents potentially affected by electrical deficiency: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce R. Leffert | Administrator | Signed the deficiency statement and plan of correction |
| Regional Maintenance Director | Helped obtain battery powered light and educated Maintenance Director on backup lighting | |
| Butler Maintenance Director | Verified findings and installed battery powered light |
Inspection Report
Plan of Correction
Census: 64
Capacity: 98
Deficiencies: 10
Date: Aug 5, 2022
Visit Reason
The document is a Plan of Correction submitted by Butler Center for Rehabilitation and Healthcare following a survey completed on August 5, 2022. It addresses deficiencies cited during the inspection.
Findings
The facility failed to meet multiple regulatory requirements including advanced directives, Medicaid/Medicare coverage notices, employee background checks, comprehensive care plans, supervision of residents with swallowing difficulties, behavioral health services, psychotropic medication management, infection prevention and control, and emergency power preparedness. Deficiencies were noted in documentation, staff training, and implementation of policies.
Deficiencies (10)
F578 The facility failed to offer or formulate advanced directives for residents as required by regulation.
F582 The facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice at Medicare Part A termination for sampled residents.
F607 The facility failed to ensure employee background checks and Federal Indicator checks were completed prior to hire for sampled employees.
F656 The facility failed to develop and implement comprehensive care plans for sampled residents.
F657 The facility failed to ensure timely care plan development, revision, and resident participation for sampled residents.
F689 The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident with dysphagia.
F740 The facility failed to provide necessary behavioral health care and services for a resident with psychosocial needs.
F758 The facility failed to ensure psychotropic drugs were used appropriately and monitored for sampled residents.
F880 The facility failed to establish and maintain an infection prevention and control program that included screening new employees for tuberculosis and other required elements.
F906 The facility failed to develop and complete an Emergency Operational Preparedness program ensuring adequate electrical power and emergency procedures.
Report Facts
Facility census: 64
Total capacity: 98
Deficiencies cited: 10
Inspection Report
Life Safety
Census: 64
Capacity: 98
Deficiencies: 13
Date: Aug 5, 2022
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code standards.
Findings
The facility was found not in compliance with emergency preparedness requirements and life safety code provisions, including deficiencies in emergency operational preparedness, means of egress, sprinkler system maintenance, fire drills, and corridor door functionality.
Deficiencies (13)
E015: The facility failed to develop a comprehensive Emergency Operational Preparedness program addressing subsistence needs, emergency operations, and continuity of essential services during emergencies.
K211: The facility failed to ensure proper release and opening of locking devices on egress doors, affecting approximately 31 residents and staff in one smoke compartment.
K353: The facility failed to maintain the sprinkler system in accordance with NFPA standards, including lack of quarterly inspections and testing.
K363: The facility failed to have residential corridor doors that resist passage of smoke and prevent propping, affecting 37 residents and staff in four smoke compartments.
K712: The facility failed to conduct required quarterly fire drills on all shifts and maintain complete documentation of fire drill activities.
A2003: No fire hazard was present as evidenced by failure to meet Class II requirements for fire safety.
A2020: The facility failed to maintain complete fire alarm system inspections and certifications annually as required.
A2031: The facility failed to complete annual sprinkler system inspections and certifications by a qualified service representative.
A2034: The facility failed to complete quarterly sprinkler system maintenance and testing as required by NFPA standards.
A2037: The facility failed to maintain required unobstructed exits and corridors, including proper door operation and fire-rated separations.
A2046: The facility failed to maintain corridors free of obstruction and ensure doors to resident rooms do not swing into corridors.
A2061: The facility failed to conduct required fire drills annually with at least one every three months on each shift, including unannounced drills.
A4013: The facility failed to develop and implement policies and procedures covering resident rights, infection control, emergency treatment, and other operational areas.
Report Facts
Resident census: 64
Total capacity: 98
Residents affected by egress door deficiency: 31
Residents affected by corridor door deficiency: 37
Number of smoke compartments: 6
Number of fire drills required annually: 12
Number of fire drills missed: 3
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
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 13
Date: Nov 21, 2019
Visit Reason
This document is a Plan of Correction submitted by Butler Center for Rehabilitation and Healthcare in response to deficiencies cited during a regulatory inspection completed on 11/21/2019.
Findings
The plan addresses multiple deficiencies related to resident rights, personal funds management, care planning, wound care, medication management, and other regulatory requirements. The facility outlines corrective actions and staff training to remedy the cited deficiencies.
Deficiencies (13)
F 550 Resident Rights: The facility failed to ensure resident dignity and privacy related to Foley catheter care and resident observation.
F 567 Personal Funds: The facility failed to obtain authorization to manage resident funds and maintain accurate records for residents' personal funds.
F 568 Accounting and Records: The facility failed to maintain accurate accounting and documentation of residents' personal funds and transactions.
F 569 Notice and Conveyance of Personal Funds: The facility failed to notify residents about balances in their personal funds accounts.
F 578 Advance Directives: The facility failed to comply with residents' Do Not Resuscitate (DNR) orders and ensure proper documentation and communication.
F 645 PASARR Screening: The facility failed to complete required PASARR Level II screening for a resident with a mental disorder.
F 658 Comprehensive Care Plans: The facility failed to develop and implement comprehensive care plans addressing residents' mental health, wound care, and other needs.
F 684 Quality of Care: The facility failed to provide adequate wound care and prevent pressure ulcers for multiple residents.
F 686 Skin Integrity: The facility failed to prevent and treat pressure ulcers and maintain skin integrity for residents at risk.
F 690 Incontinence, Catheter, UTI: The facility failed to ensure proper catheter care and prevent urinary tract infections.
F 755 Pharmacy Services: The facility failed to provide proper medication management, including narcotic counts, medication storage, and documentation of psychotropic drug use.
F 761 Label/Storage Drugs and Biologics: The facility failed to properly store and secure medications and maintain accurate medication records.
F 800 Food and Nutrition Services: The facility failed to maintain proper food temperatures and ensure safe food handling.
Report Facts
Facility census: 55
Number of sampled residents: 16
Number of sampled residents for medication review: 16
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 |
Inspection Report
Life Safety
Census: 55
Capacity: 98
Deficiencies: 16
Date: Nov 21, 2019
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety code standards.
Findings
The facility was found not in compliance with emergency preparedness requirements including tracking of staff and residents during evacuation, sheltering in place policies, communication plans, and testing of emergency procedures. Life safety deficiencies included failure to maintain fire barriers, emergency lighting testing, door self-closing mechanisms, and hazardous area protections.
Deficiencies (16)
E018: The facility failed to include a plan for tracking staff and residents if sent to other facilities during an evacuation. The facility census was 55 residents with a licensed capacity of 98.
E022: The facility failed to properly delineate circumstances for sheltering in place or evacuation, affecting all residents and staff. The facility census was 55 residents with a licensed capacity of 98.
E032: The facility failed to include actual means of communication in the emergency plan, potentially affecting all residents and staff. The facility census was 55 residents with a licensed capacity of 98.
E039: The facility failed to include a plan to schedule and conduct required tabletop and full-scale emergency exercises, potentially affecting all residents and staff. The facility census was 55 residents with a licensed capacity of 98.
K161: The facility failed to ensure an area between the attic and the area below was properly sealed against smoke passage, potentially affecting 16 residents in one smoke zone. The facility census was 55 residents with a licensed capacity of 98.
K291: The facility failed to maintain documentation of annual 1.5 hour emergency lighting testing, potentially affecting all residents and staff. The facility census was 55 residents with a licensed capacity of 98.
K321: The facility failed to ensure the door between the soiled utility room and laundry was self-closing, potentially affecting at least 25 residents in two smoke zones. The facility census was 55 residents with a licensed capacity of 98.
K324: The facility failed to ensure range hood inspections were conducted every six months, potentially affecting at least 40 residents in two smoke zones. The facility census was 55 residents with a licensed capacity of 98.
K363: The facility failed to prevent use of kickstands to keep doors open in a smoke zone, affecting one non-resident and the kitchen area. The facility census was 55 residents with a licensed capacity of 98.
K918: The facility failed to document monthly fuel testing and 30% nameplate rating for the emergency generator, potentially affecting all residents and staff. The facility census was 55 residents with a licensed capacity of 98.
A2008: Hazardous areas must be separated by at least one-hour fire-resistant construction and have self-closing or automatic closing doors. This regulation was not met as evidenced by K321.
A2017: Facilities must provide every cooking range with an approved range hood and extinguishing system maintained per NFPA 96. This regulation was not met as evidenced by K324.
A2050: Facilities must have emergency lighting of sufficient intensity for safety, supplied by an automatic emergency service. This regulation was not met as evidenced by K291.
A2058: Facilities must have written fire drills and emergency preparedness plans. This regulation was not met as evidenced by E18, E22, E32, and E39.
A3001: The building shall be substantially constructed and maintained in good repair. This regulation was not met as evidenced by K161, K363, and K918.
A4013: The facility shall develop policies and procedures to meet residents' health and safety needs. This regulation was not met as evidenced by E18, E22, E32, and E39.
Report Facts
Facility census: 55
Licensed capacity: 98
Residents affected: 16
Residents affected: 25
Residents affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding emergency lighting, door issues, and emergency preparedness testing | |
| Administrator | Interviewed regarding emergency preparedness plan and exercise scheduling | |
| Laundry Aide B | Interviewed regarding door usage and kickstand issue | |
| Dietary Manager | Interviewed regarding door lock issues in dry goods storage |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Date: Jul 9, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding sufficient and competent nursing staff on the behavioral unit and issues related to resident safety and care.
Complaint Details
The complaint investigation focused on staffing adequacy and resident safety on the behavioral unit. The facility census was 49 residents at the time of the investigation. Multiple resident incidents and staff interviews revealed insufficient staffing and lack of training. The complaint was substantiated based on these findings.
Findings
The facility failed to provide sufficient and competent nursing staff on the behavioral unit to maintain the highest practicable physical, mental, and psychosocial well-being of residents. Multiple incidents involving resident altercations and inadequate staff training on handling behaviors were documented.
Deficiencies (2)
F741: The facility failed to provide sufficient and competent nursing staff on the behavioral unit to maintain the highest practicable physical, mental, and psychosocial well-being of residents, as evidenced by multiple resident altercations and inadequate staff training.
A4044: The facility did not employ nursing personnel in sufficient numbers and with sufficient qualifications to provide nursing and related services to meet residents' needs, as evidenced by the deficiency cited in F741.
Report Facts
Facility census: 49
Behavioral unit census: 7
Behavioral unit census: 9
Behavioral unit census: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Gneil | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Certified Medication Technician (CMT) A | Interviewed regarding staffing and resident behaviors on the behavioral unit | |
| Certified Nursing Assistant (CNA) B | Interviewed regarding staffing and resident behaviors on the behavioral unit | |
| Licensed Practical Nurse (LPN) D | Interviewed regarding medication administration and staffing on the behavioral unit | |
| Director of Nursing (DON) | Interviewed regarding staffing and resident behaviors on the behavioral unit | |
| Physician #1 | Interviewed regarding resident behaviors and facility management | |
| Physician #2 | Interviewed regarding psychiatric care and staffing on the behavioral unit | |
| Police Officer #1 | Interviewed regarding facility notification and police involvement | |
| Emergency Medical Services (EMS) Supervisor #1 | Interviewed regarding emergency medication orders and facility staff education |
Inspection Report
Life Safety
Census: 42
Capacity: 98
Deficiencies: 29
Date: Sep 14, 2018
Visit Reason
An emergency preparedness portion of a Life Safety Code Survey was conducted to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility failed to develop and maintain a comprehensive emergency preparedness plan, including annual reviews and updates, patient population assessments, subsistence needs, sheltering policies, and arrangements with other facilities. Deficiencies were also found in fire safety systems including emergency lighting, fire alarm systems, sprinkler systems, and means of egress.
Deficiencies (29)
E004: The facility failed to develop and maintain an Emergency Preparedness plan that included current, signed documentation of annual reviews and updates. This affected all residents in the facility.
E007: The facility failed to have Emergency Preparedness documentation identifying and assessing residents with special needs and how to meet those needs under various contingencies. This affected all residents using such equipment.
E015: The facility failed to develop policies and procedures to maintain subsistence needs for staff and patients during emergencies, including food, water, medical and pharmaceutical supplies, and alternate energy sources.
E022: The facility failed to develop and implement emergency preparedness policies and procedures for sheltering in place for patients, staff, and volunteers.
E025: The facility failed to provide current, signed, and dated documentation of reciprocal transfer agreements with other facilities to maintain continuity of services to facility patients.
E026: The facility failed to include policies and procedures describing the facility's role under a waiver declared by the Secretary for alternate care sites during emergencies.
E030: The facility failed to develop and maintain an emergency preparedness communication plan that included names and contact information for staff, entities providing services, patients' physicians, volunteers, and others.
E036: The facility failed to develop and maintain an emergency preparedness training and testing program that is reviewed and updated annually.
E039: The facility failed to develop and maintain an emergency preparedness testing program including full-scale exercises and tabletop exercises annually.
E041: The facility failed to implement emergency and standby power systems based on the emergency plan and policies and procedures.
K161: The facility failed to ensure the fire resistance rating was maintained in specified areas including the wall in the 300 Hall Central Supply Room and ceiling of the clothes dryer area. This affected at least 33 residents.
K211: The facility failed to maintain the 100 Hall free of obstruction for 43 minutes, affecting 16 residents in one smoke zone.
K222: The facility failed to post signage indicating a 15 second delayed egress door on the 100 Hall exit door affecting 16 residents.
K291: The facility failed to ensure emergency lighting was tested and maintained, affecting all residents in eight smoke zones.
K343: The facility failed to maintain fire alarm system components, including removal of non-functioning strobe lights and alarm annunciators.
K345: The facility failed to conduct semi-annual inspection of the fire alarm system.
K351: The facility failed to ensure enclosed closets in the Therapy Office allowed access to sprinkler heads.
K363: The facility failed to ensure corridor doors resisted passage of smoke and were properly maintained and latched.
K372: The facility failed to maintain smoke barriers and penetrations between the 300 Hall and center core and 100 Hall and center core.
K914: The facility failed to maintain electrical systems including receptacles and circuit breakers, and failed to keep records of inspections and testing.
A1135: The facility failed to provide emergency lighting for exits, stairs, corridors, and nurses' stations as required by NFPA 99.
A2018: The facility failed to provide a complete fire alarm system including interconnected smoke detectors and visual and audible alarms.
A2019: The facility failed to test and maintain the complete fire alarm system as required.
A2035: The facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13.
A2046: The facility failed to maintain corridors free of obstruction, equipment, or supplies.
A2054: The facility failed to maintain smoke section walls and doors with required fire ratings and automatic closing.
A3001: The facility failed to maintain the building in good repair and comply with physical plant requirements.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70.
A4013: The facility failed to develop and implement policies and procedures covering personnel practices, admission, discharge, nursing practices, and infection control.
Report Facts
Facility census: 42
Total licensed capacity: 98
Number of smoke zones: 8
Number of residents affected by fire resistance rating deficiency: 33
Number of residents affected by corridor obstruction: 16
Number of residents affected by delayed egress door signage: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to emergency preparedness, fire safety inspections, and corrective actions | |
| Interim Administrator | Interviewed regarding emergency preparedness plan and record reviews | |
| Dietary Supervisor | Interviewed regarding facility operation and emergency contact lists | |
| Director of Nursing | Interviewed regarding corridor obstruction and staff education | |
| Administrator | Named in plan of correction and interview |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 12
Date: Sep 14, 2018
Visit Reason
The inspection was the annual survey of Butler Center for Rehabilitation and Healthcare to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, management of personal funds, safe environment, activities, quality of care, skin integrity, infection control, and equipment maintenance. Several residents were affected by these deficiencies.
Deficiencies (12)
F550 Resident Rights/Exercise of Rights. The facility failed to ensure privacy and dignity for residents by not properly closing doors and pulling curtains during care.
F567 Protection/Management of Personal Funds. The facility failed to provide written statements of residents' personal funds in a clear and understandable manner at least quarterly.
F568 Accounting and Records of Personal Funds. The facility failed to obtain correct resident or designee signatures on Resident Trust Fund accounts for two sampled residents.
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a shower chair in clean condition and failed to maintain fans free of dust in resident rooms.
F679 Activities Meet Interest/Needs Each Resident. The facility failed to ensure activities met individual resident interests and abilities for two sampled residents.
F684 Quality of Care. The facility failed to provide necessary treatment and services for a resident's cancer wound and pressure ulcers.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide ongoing wound care and documentation for a resident with Stage 4 pressure ulcers.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to ensure safe operation of a mechanical lift, exposing residents to potential risk.
F761 Label/Store Drugs and Biologicals. The facility failed to ensure safe storage and labeling of medications and biologicals, including expired items.
F813 Personal Food Policy. The facility failed to ensure safe storage and handling of foods brought in by visitors, risking resident safety.
F880 Infection Prevention & Control. The facility failed to maintain an effective infection prevention program including hand hygiene and catheter bag placement.
F908 Essential Equipment, Safe Operating Condition. The facility failed to maintain two clothes dryers in working condition, impacting laundry services.
Report Facts
Deficiencies cited: 12
Resident census: 42
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 2
Date: Apr 12, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to resident safety and protective oversight, specifically regarding a resident leaving the facility against medical advice and the facility's failure to provide adequate supervision and protective oversight.
Findings
The facility failed to ensure a resident environment free of accident hazards by allowing a resident to leave the facility against medical advice without appropriate safety interventions. The facility also did not follow proper procedures for transfer or discharge notices and failed to provide adequate supervision and protective oversight for residents on voluntary leave.
Deficiencies (2)
F689: The facility failed to provide protective oversight for a resident who left against medical advice, resulting in safety risks. The resident's discharge and transfer procedures did not comply with required notification and documentation policies.
A4073: The facility did not meet the regulation for protective oversight during voluntary leave, failing to ensure 24-hour supervision and procedures to track residents' whereabouts while on leave.
Report Facts
Resident census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shyla L. Buxton | Administrator | Signed the plan of correction |
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