Butler Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Butler Rehab and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 27, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF906Aug 5, 2022

  Based 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. […]

• No harm, potential for more than minimal, patternF584Feb 27, 2026

  Based 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;… […]

• No harm, potential for more than minimal, patternF880Feb 27, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF552Apr 29, 2025

  Based 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. […]