Medicalodges Butler

Inspectors wroteBased on observation and interview, the facility failed to maintain required negative airflow in the following areas: The South Hall Soiled Utility Room, resident rooms 132, 130 and 128. This practice potentially affected at least 10 residents who resided on the [NAME] Short Hall where the South soiled utility room was located and rooms on the South Hall. The facility census was 65 residents.**Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn to the vent, then negative air flow was present; if the paper fell, then negative airflow was absent. Observations on 9/4/25 with the Maintenance Supervisor showed:-At 11:53 A.M., there was the absence of negative airflow in the South side soiled utility room. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the attic areas over the short [NAME] Hall, and the attic area over the South Hall free from openings that could allow pests into the attic areas and failed to maintain those attic areas free from numerous animal droppings (the waste product of animals). This practice potentially affected 17 residents who resided on or used those halls. The facility census was 65 residents.1. Observation on 9/3/25 at 12:34 P.M., with the Maintenance Supervisor, showed a 15 inch (in.) long by 1 in. wide opening along the outer wall of the attic above the short [NAME] Hall along with numerous amounts of animal droppings in that attic area. Observation on 9/3/25 at 12:46 P.M., with the Maintenance Supervisor showed a 15 in. long by 3 in. [...]

Inspectors wroteBased on interview and record review, the facility failed to invite two residents (Resident #7 and Resident #55) to care plan meetings out of 16 sampled residents. The facility census was 63 residents. A policy was requested from the facility for care plan meetings and was not provided. Review of the undated Care Plan Invitation Form showed:-A place for the residents' name.-Three boxes in which one would be checked for if the person invited would be:-Attending in person.-Join in by telephone.-If neither the resident, nor family member would be in attendance. 1. Review of Resident #7's admission record showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a prompt resolution to a grievance filed by one sampled resident (Resident #55) out of 16 sampled residents. The facility census was 65 residents. Review of the facility's policy titled Grievances dated June 2019 showed:-The facility created the policy to ensure the prompt resolution of grievances.-Grievances may include those with respect to care and treatment, behavior of staff and other residents, and any other concerns a resident may have.-Residents and others could expect contact from the facility's Grievance Officer typically within seven to ten days following the voicing of a grievance.-There was not specific time frame in the policy related to the timing of the resolution of the grievance.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman of a planned discharge for one resident (Resident #77) out of 16 sampled residents and three closed records. The facility census was 63 residents. A policy was requested from the facility for Ombudsman notification and was not provided. 1. Review of Resident #77's admission record showed the resident was admitted to the facility on [DATE]. Review of the resident's care plan dated 7/12/25 showed:-The resident was admitted for skilled nursing services for a fall with a fractured hip.-The plan was to discharge home. Review of the resident's Progress notes dated 7/18/25 showed:-The resident was discharged home.-The resident was alert and oriented and able to make decisions. -The resident was safe to discharge home. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and direct the care of one sampled resident's (Resident #38) cardiac pacemaker (a small battery-operated device surgically implanted in the body to deliver electrical pulses to help the heartbeat at a normal rate and rhythm), and failed to develop a policy to direct staff responsibilities involved in the care of residents with pacemakers and/or implanted medical devices out of 16 sampled residents. The facility census was 65 residents. A pacemaker policy was requested and not received. 1. Record review of Resident #38's hospital referral information, page nine of six, dated 6/10/25 showed a past surgical history of pacemaker implantation. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow a Registered Dietician (RD) supplement recommendation for one sampled resident (Resident #65) out of 16 sampled residents. The facility census was 65 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the correct insulin Lantus (a long acting insulin)10 units but instead gave the resident Novalog (fast acting insulin) 10 units at 8:00 P.M., to one sampled resident (Resident # 1) out of three sampled residents. The facility census was 68 residents. On 6/5/25 the Administrator and acting Director of Nursing (DON) were notified of past non-compliance which occurred on 3/7/25. On 3/8/25 the facility administrator was notified of the incident by Licensed Practical Nurse (LPN) A and the investigation was started. LPN A was educated on 3/8/25 and was given a written warning on 3/10/25. Employee education started on 3/8/25 before the start of there shift and finished on 4/3/25. The deficiency was corrected on 3/8/25. Review of the facility's policy Medication Administration General Guidelines dated 1/25 showed: [...]

Inspectors wroteBased on observation and interview, the facility failed to remove dust and food debris from under the reach-in refrigerators at the back of the kitchen; failed to maintain the gasket (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) in the door to the white upright freezer in good repair; failed to remove a buildup of dust from the sprinkler heads over the 3 compartment sink, the sprinkler heads and pipes over the automated toaster and ice maker machine; and failed to remove debris from the spray wand of the automated dishwasher. This practice potentially affected all residents in the facility. The facility census was 70 residents. 1. Observations on 3/25/24 from 9:18 A.M. through 9:38 A.M., during the initial kitchen tour, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Third Party Liability (TPL- a form that is used by nursing homes to present a complete account of all the resident's remaining personal funds after a resident passed away) form was completed and submitted to MO Health Net within 30 days of death for three deceased residents (Residents #219, #220, and #221); and the facility failed to ensure a check with the remaining funds was submitted within 5 days of discharge for one discharged resident (Resident #218. This practice potentially affected four discharged residents. The facility census was 70 residents. 1. Review of Resident #219's resident fund information showed: - The resident passed away on [DATE]; at the time of the resident trust review, it had been 36 days since the resident's death. - The resident had $200.11 in his/her account when he/she passed away. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was negative airflow as required in the soiled utility room close to the South Hall and in the restrooms of the following resident rooms: 123, 122, 102, and the restrooms of shared rooms of 30/28, 31/33, 29/27, 19/21, 16/14, 15/17, 12/10 and 13/11. This practice potentially affected at least 20 residents who resided in or used those areas. The facility census was 70 residents. **Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn up then negative air flow was present; if the paper was not drawn to the ceiling vent, then negative airflow was absent. 1. Observation with the Maintenance Director on 3/26/24, showed: - At 12:09 P.M., there was not any negative airflow in the soiled utility room close to the south nurse's station. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the East hall attic area free of openings that could let in potential pests, and failed to maintain that attic area free of debris that indicated evidence of pests; failed to maintain the South hall attic area free of hay/straw which indicated the presence of pests and failed to maintain the tat area over the dementia unit free of pests which were once in that attic as evidenced by animal droppings and the presence of feathers. This practice potentially affected 40 residents who resided in or used those areas. The facility census was 70 residents. 1. Observation on 3/26/24 at 9:19 A.M., with the Maintenance Director of the East attic area showed: - Two openings at the outer wall end of the attic where the screen was not properly sealed against the entrance of pests. - The presence of some type of nest. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update the intervention for the continued use of a knee brace for one sampled resident (Resident #2); to update the care plan with new interventions as needed; and to ensure the fall care plan was implemented for one sampled resident (Resident #41) who fell after being left alone in the dining room and did not have on proper footwear out of 18 total sampled residents. The facility census was 70 residents. Review of the facility's Falls Management policy revised 12/22/22 showed: -The fall assessment should be completed upon admission, quarterly, with a significant change and each fall occurrence. -If identified risk is present the interventions should be communicated to facility staff on the care plan. -After a fall occurs the licensed nurse would initiate a risk management event reporting process to include: [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled resident (Resident #63), with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), out of 18 sampled residents. The facility census was 70 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility. The facility census was 68 with a licensed capacity for 110. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen and the dry storage floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to maintain plastic cutting boards to avoid food safety hazards; to follow correct hair hygiene practices; and to separate damaged foodstuffs. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 68 residents with a licensed capacity for 110 residents. 1. Observations during the initial kitchen inspection on 6/27/22 between 10:01 A.M. and 12:38 P.M. showed the following: [...]