Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medicalodges Butler during CMS and state inspections, most recent first.
An LPN administered 10 units of Humalog insulin instead of the prescribed 10 units of Lantus to a resident with Type II Diabetes Mellitus, after failing to verify the medication against the MAR and not checking the insulin pen from the emergency kit. The error was discovered hours later when the resident's blood sugar was found to be critically low, prompting immediate intervention.
The facility failed to maintain cleanliness and proper maintenance in the kitchen, with food debris and dust buildup under refrigerators, behind the ice machine, and on sprinkler heads. A 9-inch crack was found on the freezer gasket, and debris was present in the dishwasher spray wand. Interviews confirmed lapses in cleaning routines and maintenance.
The facility failed to submit TPL forms to MO Health Net within 30 days of death for three deceased residents and did not submit a check with remaining funds within 5 days of discharge for one resident. The BOM admitted to delays and lack of awareness of regulatory requirements, affecting four discharged residents.
The facility failed to ensure negative airflow in the soiled utility room and restrooms of multiple resident rooms, potentially affecting at least 20 residents. Observations and interviews revealed that switches controlling the negative air flow vents were either turned off or not working, leading to the deficiency.
The facility failed to maintain the East hall attic area free of openings and debris indicating pests, the South hall attic area free of hay/straw, and the dementia unit attic free of animal droppings and feathers. The Maintenance Director confirmed these issues during a survey and admitted to limited access during monthly inspections. These deficiencies potentially affected 40 residents, with a facility census of 70.
The facility failed to update care plans and implement interventions for two residents, leading to falls and injuries. One resident, with a history of hemiplegia, fell and fractured bones due to not wearing a knee brace during a transfer. Another resident with Alzheimer's was left alone in the dining room and fell, resulting in a hematoma. The care plans were not adequately reviewed and revised, and staff did not consistently follow the interventions.
A facility failed to identify, assess, and provide supportive interventions for a resident with PTSD. The care plan did not address the resident's PTSD, including triggers and interventions. Staff were unaware of the resident's PTSD diagnosis, and the MDS Coordinator acknowledged the care plan's deficiencies. The DON confirmed the expectation for complete care plans and staff awareness, but the care plan was found to be inadequate.
Failure to Administer Correct Insulin Resulting in Significant Medication Error
Penalty
Summary
A medication administration error occurred when an LPN administered 10 units of Humalog insulin to a resident instead of the prescribed 10 units of Lantus insulin at bedtime. The LPN obtained the insulin from the emergency kit after noticing the resident was out of Lantus, but failed to verify the medication against the resident's Medication Administration Record (MAR) and did not check the insulin pen to ensure it was the correct drug. This action was not in accordance with the facility's policy, which requires verification of medication orders and the medication itself at multiple points prior to administration. The resident involved had a diagnosis of Type II Diabetes Mellitus and was cognitively intact, with orders for regular blood glucose monitoring and specific insulin regimens: Lantus at bedtime and Novolog three times daily. On the day of the incident, the resident's blood sugar readings were within normal limits prior to the error. After the incorrect administration of Humalog, the LPN discovered the error several hours later while reviewing paperwork, prompting immediate assessment of the resident's blood sugar, which was found to be critically low. The LPN did not follow the established rights of medication administration, specifically failing to confirm the correct medication and dosage before administration. The error was self-identified by the LPN, who then notified the appropriate clinical staff and initiated measures to address the resident's hypoglycemia. The incident was documented in the facility's records, and interviews confirmed that the LPN did not adhere to the required medication administration procedures, leading to the significant medication error.
Kitchen Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in the kitchen area, which potentially affected all residents. Observations revealed a buildup of food debris and dust under the reach-in refrigerators, behind the ice-making machine, and on the sprinkler heads and pipes over the 3-compartment sink and automated toaster. Additionally, a 9-inch crack was found on the gasket of the white upright freezer. These issues were noted during an initial kitchen tour and subsequent observations, indicating a lack of regular cleaning and maintenance routines. Interviews with the Dietary Manager (DM) and Dietary Aides (DA) confirmed the deficiencies. The DM admitted to notifying the Maintenance Assistant about the need for cleaning three weeks prior but had not noticed the damaged gasket on the freezer. The DM also acknowledged that the spray wands of the automated dishwasher, which were supposed to be cleaned nightly, still had debris. The DA responsible for washing dishes did not notice the debris in the dishwasher spray wand. These lapses in cleanliness and maintenance practices were observed over multiple days, highlighting ongoing issues in the facility's kitchen management.
Failure to Submit TPL Forms and Resident Funds Timely
Penalty
Summary
The facility failed to ensure that Third Party Liability (TPL) forms were completed and submitted to MO Health Net within 30 days of death for three deceased residents and failed to ensure a check with the remaining funds was submitted within 5 days of discharge for one discharged resident. Specifically, Resident #219 passed away with $200.11 in their account, and the TPL form was not submitted within the required 30 days. Resident #220 passed away with $87.30 in their account, and the TPL form was also not submitted within the required timeframe of 30 days. Resident #221 had $498.65 in their account at the time of death, and the TPL form was submitted 70 days after the resident's death. Additionally, Resident #218 was discharged with a balance of $20.00 in their account, and the check for the remaining funds was not submitted within the required 5 days of discharge due to a delay caused by a hair care charge that was known at the time of discharge but not immediately processed. During interviews, the Business Office Manager (BOM) admitted to sending checks to funeral homes and the state but failing to complete and submit the TPL forms within the required 30 days for deceased residents. The BOM also acknowledged the delay in processing the check for the discharged resident due to the hair care charge. The BOM was unaware of the requirement to fill out and submit TPL forms for any resident receiving Medicaid or Medicare, indicating a lack of proper training or understanding of the regulatory requirements. This deficiency potentially affected four discharged residents in a facility with a census of 70 residents.
Failure to Maintain Negative Airflow in Soiled Utility Room and Resident Restrooms
Penalty
Summary
The facility failed to ensure there was negative airflow as required in the soiled utility room close to the South Hall and in the restrooms of multiple resident rooms. This deficiency was identified through observations and interviews conducted on 3/26/24 and 3/27/24. During the inspection, it was observed that there was no negative airflow in the soiled utility room near the south nurse's station and in the restrooms of resident rooms 123, 122, 102, and several shared rooms. The negative airflow was tested by holding a piece of tissue paper to the ceiling vent; the paper was not drawn up, indicating the absence of negative airflow. This issue potentially affected at least 20 residents who resided in or used those areas, with the facility census being 70 residents. During interviews, the Maintenance Director revealed that a switch controlling the negative air flow vents in the North and East areas had been turned off in the attics. Additionally, the switch controlling the ceiling vents in the South side areas, including the soiled utility room and several resident rooms, was no longer working. The Administrator admitted that back in January 2024, during extremely cold weather, they had requested the ceiling vents be turned off to reduce drafts. This action led to the current deficiency in maintaining proper negative airflow in the specified areas.
Pest Control Deficiency in Attic Areas
Penalty
Summary
The facility failed to maintain the East hall attic area free of openings that could let in potential pests and failed to keep the area free of debris indicating evidence of pests. Additionally, the South hall attic area was not maintained free of hay/straw, suggesting the presence of pests, and the attic area over the dementia unit contained animal droppings and feathers, indicating past pest activity. These deficiencies were observed during a survey on 3/26/24, where the Maintenance Director confirmed the presence of two openings in the East attic, a nest, a large amount of hay/straw in the South attic, and straw/hay, feathers, and animal droppings in the dementia unit attic. The Maintenance Director admitted during a phone interview on 4/4/24 that he/she inspected the attic areas once per month but was unable to access all areas, leading to the unnoticed hay/straw towards the outer wall. These issues potentially affected 40 residents who resided in or used those areas, with the facility census being 70 residents.
Failure to Update Care Plans and Implement Interventions
Penalty
Summary
The facility failed to update the intervention for the continued use of a knee brace for one resident and to update the care plan with new interventions as needed. The resident, who had a history of hemiplegia and hemiparesis following a stroke, experienced a fall resulting in fractures due to not wearing the knee brace during a transfer. The CNA assisting the resident did not ensure the knee brace was on before the transfer, which was a requirement according to the resident's care plan. The resident's care plan was not updated with new interventions following the fall, and the resident was subsequently transferred using a mechanical lift due to the injury sustained from the fall. Another resident, who had Alzheimer's disease and a history of falls, was left alone in the dining room and fell, resulting in a hematoma. The resident's care plan included an intervention to not leave the resident unattended in the dining room, which was not followed. The resident was also not wearing proper footwear at the time of the fall, which was another care plan intervention that was not implemented. The CNA on duty admitted to leaving the resident alone in the dining room to attend to other residents, despite knowing the resident should not be left unattended. The facility's failure to update care plans with new interventions and ensure the implementation of existing interventions contributed to the falls and injuries of the two residents. The care plans were not adequately reviewed and revised following fall incidents, and staff did not consistently follow the care plan interventions, leading to preventable accidents and injuries.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's care plan did not address PTSD, including the resident's triggers and interventions. Despite the resident being on an antidepressant medication for PTSD, the care plan lacked specific details on how to manage the condition effectively. Interviews with the resident and staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis, triggers, and necessary interventions. The resident expressed that the facility was not addressing their PTSD, which stemmed from past military service. Staff members, including a Certified Medication Technician (CMT), Certified Nurse's Assistant (CNA), and Registered Nurse (RN), were unaware of the resident's PTSD diagnosis, triggers, or interventions. The MDS Coordinator, responsible for care plan development, acknowledged that the care plan should have included this information but did not. The Director of Nursing (DON) confirmed that it was the MDS Coordinator's responsibility to ensure the care plan accurately reflected the resident's condition, including PTSD triggers and interventions. The DON also stated that the Inter-disciplinary Care Team (IDT) audited the care plans and that it was their expectation that all staff would be aware of a resident's triggers and interventions. However, the care plan for the resident with PTSD was found to be incomplete and inadequate, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Butler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Butler Rehab And Healthcare Center | 0.5 mi | — | 27 | 0 |
| Baptist Homes Of Adrian | 10.1 mi | — | 15 | 0 |
| Appleton City Manor | 17.3 mi | — | 2 | 1 |
| Nathan Richard Health Care Center | 27.1 mi | — | 2 | 0 |
| Medicalodges Nevada | 28 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.