Butler Rehab and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party for one closed record sampled resident's (Resident #1) significant change of condition when on 05/24/26 the resident acquired an unstageable (full thickness and tissue loss has occurred but the true depth of the damage cannot be assessed because the wound bed is obscured by dead tissue), necrotic (death of living tissue or cells) pressure injury/ulcer to his/her coccyx (base of spine, tailbone) out of three residents sampled for pressure injury/ulcer. The facility census was 54 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were met related to the monitoring and documentation of pacemaker (an electrical device that stimulates the heart at a fixed rate) functionality for one sampled closed record resident (Resident #1) and one sampled resident (Resident #2) out of 2 residents sampled for heart monitoring devices. The facility census was 54 residents. Review of the facility's Care and Services policy revised 10/24/22 showed:-Purpose: To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process.-The licensed nurse or designee documents and notifies the resident's physician and responsible party of unusual circumstances. [...]

Inspectors wroteBased on observation an interview, the facility failed to prevent the accumulation of debris on the blade of the table top can opener; failed to remove the accumulation of food particles and debris from under the 6-burner stove; failed to prevent a buildup of dust on the vent fans and the sprinkler head in the walk-in refrigerator; failed to prevent the accumulation of dust and grease on the light fixtures; and failed to prevent the presence of a dust buildup inside the ceiling vents in the kitchen. This practice potentially affected 58 residents who ate food from the kitchen. The facility census was 59 residents. 1. Observation on 2/23/26 from 9:56 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the ceiling vents in the following areas free from a buildup of dust, the dining room, the shared restroom between 308 and 310, 300 Hall Central bath, the shared restroom between 306 and 304, resident room [ROOM NUMBER], resident room [ROOM NUMBER], 100 Hall Central Bath, and the 200 Hall Central Bath; failed to maintain the floor in good repair and in an easily cleanable condition in the shared restroom of resident rooms [ROOM NUMBERS], the 300 Hall Central Bath, the restroom floor in resident room [ROOM NUMBER], and the restroom floor in resident room [ROOM NUMBER]; failed to maintain the floors in the following areas clean and free of debris, resident rooms 313, 307, 304, 302, 305, 303, 300, 111, 105, 106, and 102; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene and Enhanced Barrier Precautions (EBP - infection control measures of gown and glove use during high contact activities with residents at risk for transmission germs resistant to many antibiotics) for one sampled resident (Resident #47) with a physician's order for EBP and failed to develop a facility policy that instructed nursing staff in the use of gowns with EBP and that included the use of EBP for residents with indwelling devices (medical devices inserted into the body); failed to ensure staff used hand hygiene after insulin (medication used to manage diabetes (Types 1, 2, or gestational) administration after removing gloves and before applying new ones for one supplemental resident (Resident #31); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that only residents assessed and determined safe by the interdisciplinary team (IDT) may self-administer medication and failed to ensure medications were not left unattended for a resident assessed as unable to self-administer for one sampled resident (Resident #17) out of 14 sampled residents. The facility census was 59 residents. The Medication Self-Administration policy was requested on [DATE] but was not provided before exit time. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit a Third Party Liability (TPL- a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account) forms were completed and sent to Missouri (MO) Healthnet (a state agency which administers the provision and payment of services for Missouri's Medicaid program) within 30 days of death for one discharged resident (Resident #11) out of three sampled residents selected for TPL submission review. The facility census was 59 residents. 1. Review of Resident #11's medical record showed the resident died on [DATE]. Review of the resident's Trust Fund Balance showed the resident had a balance of $8.68 in his/her account. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility policy and procedure for checking the Criminal Background Check was followed for two sampled employees (Maintenance Worker A and Certified Nursing Assistant (CNA) C) out of 10 sampled employees. The facility census was 59 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive investigation was completed that included details of the circumstances of the fall, notification of the emergency contact/family and completing the risk analysis of what occurred and interventions implemented to prevent the fall from recurring for one sampled resident (Resident #9) who fell, sustaining a minor injury and who was confused and unable to make decisions independently out of 14 sampled residents. The facility census was 59 residents. Review of the facility's Fall Prevention policy and procedure dated 10/24/22, showed:-Following a resident's fall, the licensed nurse will complete an incident report and a Post Fall Assessment & Investigation within 24 hours or as soon as practicable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order and failed to update the care plan for one sampled resident (Resident #1) to provide own self-care for his/her Colostomy (bowel) and Urostomy (bladder) (surgical openings (stomas) in the abdomen allowing waste to exit the body into a pouching system, used when bowel or bladder function is compromised) out of 14 sampled residents. The facility resident census of 59 residents. Review of the facility Policy and Procedure for Colostomy care revised on 10/24/22 showed: The stoma and surrounding skin will be monitored for irritation with routine care and as part of licensed nurses' weekly assessment. Requested the facility policy for self-administrating of medication and treatments and did not receive at time of exit. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's order prescribed enteral supplemental tube feeding (tubes inserted into the gastrointestinal tract to provide a patient with enteral nutrition) formula and failed to update the resident's care plan to include details on the prescribed tube feeding formula for one sampled resident (Resident #7) who was dependent on enteral nutritional feedings out 14 sampled residents. The facility census of 59 residents. Requested the facility's Tube Feeding policy did not receive at time of exit. Review of the tube feeding formula manufacture information on website dated 2026 showed: -Diabetisource AC 1.2 calories (cal) per milliliter (ml) (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables for resident that are diabetic for reduce sugar intake). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory face masks and tubing were covered to prevent cross contamination when not in use for two sampled residents (Resident #13, and #6) out of 14 sampled residents. The facility census was 59 residents. Review of the facility Oxygen Administration policy and procedure dated 10/24/22, showed:-All oxygen tubing, humidifiers, masks and cannulas used to deliver oxygen are for single resident use only and will be changed weekly when visibly soiled or as indicated.-Oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a cold dish (cottage cheese fruit plate) was served at a temperature at or close to 41 F (degrees Fahrenheit) to three residents who received room trays and resided on the 100 Hall. The facility census was 59 residents. 1. Review of the undated recipe for cottage cheese fruit plate, showed:-Ingredients which included lettuce leaves, cottage cheese, diced peaches, diced fruit and maraschino cherry halves.-Methods which included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) chicken tenders were a smooth consistency. This practice potentially affected two residents with pureed diets. The facility census was 59 residents. 1. Review of the undated recipe for pureed baked chicken, for 1 serving, showed:-1 serving of baked chicken.-Chicken base to taste with 1 ounce of water. -Commercial thickener (a substance such as cornstarch or other carbohydrate which is added to foods to increase the viscosity of liquids without altering their, taste). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and appropriate discharge when the facility staff sent one resident, (Resident #1) out of seven sampled residents, to the hospital with discharge paperwork indicating to return the resident to a homeless shelter in the city. The facility census was 55 residents. A discharge policy was requested from the facility and not received.1. Review of Resident #1's face sheet, undated, showed:-The resident was admitted to the facility on [DATE].-The resident was his/her own representative. Review of the resident's quarterly Minimum Data Set (MDS-a standardized assessment tool that measured health status in nursing home residents) dated 5/22/25, showed:-The resident was cognitively intact. [...]

Inspectors wroteBased on interview and record review, contracted Physical Therapy Assistant (PTA) A did not adhere to resident's rights to be informed of care or refuse care by not explaining each treatment he/she was providing for seen residents prior to providing their treatments for seven residents (Residents #1, #2, #3, #4, #5, #6 and #7) causing those residents to feel uncomfortable with the PTA A's treatments out of eleven sampled residents. The facility census was 77 residents. On 4/29/25, the facility Administration was notified of the past noncompliance which occurred on 4/21/25. Facility staff were educated on resident rights, informed care, abuse and neglect protocols and customer service. The deficiency was corrected on 4/21/25. Review of the facility's Resident Rights-Quality of Life Policy revised on May 1, 2023 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #29) care plan was updated to reflect an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed); failed to ensure one sampled resident's (Resident #18) care plan was updated to reflect requiring assistance / supervision with smoking; failed to ensure one sampled resident's (Resident #38) care plan was updated to reflect his/her current pain level, frequency, and interventions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were screened for Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for four sampled residents (Resident #29, #38, #47, and #50) out of 15 sampled residents; and failed to properly screen new employees for TB for two sampled employees, (Employee's G and J) out of ten sampled new employees prior to hire. The facility census was 56 residents. Review of the facility's policy (Tuberculosis - Screening) dated October 24, 2022 showed: -The facility screened residents for TB upon admission, readmission, and as indicated thereafter. -Any resident without documentation receives a baseline (two-step test) upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The facility census was 56 residents. A policy was requested and not provided by the time of exit. 1. Review of the list of current employees who were CNA's showed three CNA's were chosen for records to be reviewed for the required 12 hour training/in-services. 2. Review of CNA B's training record dated April 2023 to April 2024 showed he/she was hired on 8/27/21 and worked as needed (PRN) and attended the following in-services: -On 4/28/23 nurses meeting (did not say what the topic was). -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), New owner. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a spend down plan for two sampled residents (Resident #13 and #18) out of two residents sampled for the resident fund review process, who maintained a balance of more than $5,726.00 (the legal Missouri Medicaid limit) in their account for more than one month. The total facility census was 56 residents. Review of the facility's policy titled Resident's Funds Handling and Recording revised 10/24/22 showed: -The facility would notify the resident if his/her Resident Trust Fund (RTF) account was within $200.00 of the Social Security Income (SSI-Medicaid) legal limit. 1. Review of Resident #13's RTF statements showed: -On 9/1/23 the resident's balance was $8049.94. -On 10/3/23 the resident's balance was $8806.38. -On 11/3/23 the resident's balance was $8993.86. -On 12/30/23 the resident's balance was $9303.54. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly and accurately document a resident's advanced directives (wishes for what procedures, if any, a person would like to have should the heart stop beating and/or they stopped breathing) by reporting full code (giving the resident Cardiopulmonary Resuscitation CPR- An emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) and Do Not Resuscitate (DNR-do not provide life-saving measures) on the resident's care plan for one sampled resident (Resident #27) out of 15 sampled residents. The facility census was 56 residents. Review of the facility's Advance Directives Policy, dated [DATE], showed: -The facility respected a resident's advance directive and complied with the resident's wishes expressed in the advance directive. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy to conduct Criminal Background Checks (CBC) for new employees, not having on the policy to check the Nurses Aide (NA) Registry (a data base that provided the list of eligible nursing assistants who can be employed by long-term care facilities as health workers) for all employees prior to hire, and not completing a check of the NA Registry for two sampled employees (Employee B and Employee F) out of ten sampled new employees. The facility census was 56 residents. Review of the facility's Staff Screening policy, dated 10/24/22, showed: -Prior to employment the facility verified and documented or obtained a copy of the following information: --Previous/current employer regarding work history, allegations of abuse against residents, employees, or others. --Criminal Background Checks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment/services, equipment, supplies or assistance to maintain and improve range of motion (ROM) and mobility for one sampled resident (Resident #38) reviewed for ROM out of 15 sampled residents. The facility census was 56 residents. Review of the facility policy titled Range of Motion Exercises dated 10/24/22 indicated: -Staff used a physician order to deliver ROM exercises to residents. -The exercises were used to prevent/decrease contractures and increase ROM for a joint. 1. Review of Resident #38's undated face sheet indicated he/she had the following diagnoses: -Cerebral infarction (stroke). -Dysphasia (impairment in the production of speech resulting from brain disease or damage). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's monthly pharmacy Drug Regimen Review (DRR) recommendations were reviewed and acted upon by the physician, for one sampled resident (Resident #29), out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Drug Regimen Review dated 10/24/22 showed: -The pharmacist was responsible for reviewing each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. -The pharmacist was responsible for reporting any irregularities to the Attending Physician, the facility's Medical Director, and the Director of Nursing (DON), and these reports must be acted upon. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #25 and #51) received dental services for broken teeth out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy, Dental Services dated October 24, 2022 showed: -It was the responsibility of each staff member within the nursing department to ensure good oral care for each resident. -An assessment of the oral cavity and teeth was to have been preformed upon admission and as necessary. -Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. -Note any such condition in the resident's chart. -Report problem to the charge nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and complete Emergency Operational Preparedness (EOP) program that included plans and procedures relating to the electrical power system where the critical safe devices, appliances and facility fixtures and systems were not listed as being supported by the essential electrical systems (EES) or generator. The lack of emergency operational ability and functionality of the facility would have a direct effect on the residents and staff in the event of a normal electrical supply being interrupted during an emergency or evacuation. This deficient practice potentially affects all residents, family, visitors, and staff who reside, use, visit, volunteer, or work in the facility's six facility smoke compartments. The facility census was 64 residents with a capacity for 98 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBCs), and/or the Nurse Aide (NA) Registry were completed prior to hire, re-hire, and/or periodically, and to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for ten out of ten sampled employees. The facility census was 64 residents. Record review of the facility's Employee Background Checks (Screening) F606 policy last revised 11/2017 showed: -Background checks are completed per state guidelines on each employee. [...]

Inspectors wroteBased on interview and record review, the facility failed to the extent practicable, to include residents and their representatives in the care planning process and to conduct care plan conferences to include resident/resident representative participation for four sampled residents (Residents #38, #16, #20, and #22) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Comprehensive Care Plans revised 11/2017 showed: -The facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family member or representative, developed and maintained a comprehensive care plan for each resident that identified the highest level of function the resident may be expected to obtain. -Assessments of residents were ongoing and care plans revised as information about the resident's conditions changes. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from the pharmacist for Gradual Dose Reduction (GDR) of psychotropic medications (drugs which affect psychic function, behavior, or experience) were acted upon or acted upon timely by the resident's physician for four sampled residents (Resident's, #33, #20 #50, and #38) out of 16 sampled residents. The facility census was 64 residents. Record review of Policy titled Tapering Medications and Gradual Dose Reduction-F 758 dated 9/2012 and revised 11/2017, and last approved on 5/2022 showed: -Tapering of medications and gradual dose reductions would be completed in consultation with the Attending Physician and Consultant Pharmacist and would be conducted per CMS guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases when the facility failed to properly screen new employees for tuberculosis ((TB) a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five out of ten sampled new and continuing employees (Employees C, E, F, I and J) prior to and after their hire date per the facility policy. The facility census was 64 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer/formulate advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for two sampled residents (Resident #50 and #16) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Advanced Directives revised 11/2017 showed: -Prior to or upon admission written information would be given to the resident/family regarding formulating advanced directives and request any current advanced directives. -The advanced directives would be reviewed annually. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the termination of Medicare Part A benefits for two sampled residents (Resident #47 and #43) out of two sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 64 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09 showed: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for three sampled residents (Resident #8, #38, and #51) out of 16 sampled residents. The facility census was 64 residents. Record review of Policy titled Care Plans-Comprehensive-F 656, F 657, F 658 dated 9/2012 and revised 11/2017, and last approved on 5/2022 showed: -An individualized comprehensive person centered care plan that included measurable objectives and time frames that met the resident's medical, nursing, mental, and psychological needs was developed for each residents. -Person Centered Care: A focus on the resident as the locus of the community and supported the resident in making their own choices and having control over their daily lives. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision while eating and drinking for one sampled resident (Resident #50) out of 16 sampled residents who had a diagnosis of dysphagia (inability or difficulty swallowing). The facility census was 64 residents. A policy was requested related to supervised eating but it did not contain information on residents with swallowing issues. 1. Record review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Stroke. -Dysphagia. -Aphagia (loss of ability to produce or comprehend language due to brain injury). Record review of the resident's physician's Order Summary Report (OSR) dated 3/15/22 showed a order for a regular diet with mechanical soft chopped meat and regular thin liquids. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression and physical aggression for one sampled resident (Resident #50) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Behavioral Health Services revised 11/2017 showed: -The facility should assess the resident for needed behavioral health services upon admission, quarterly and with a change of condition. -Apply a person centered approach to care which included knowledge of each individual's daily routine, lifelong patterns, interests, preferences and choices. -Interact and communicate with the resident in a manner that promoted mental and psychosocial well-being. 1. [...]