Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Butterfield Trail Village during CMS and state inspections, most recent first.
A facility failed to ensure that nurses and nurse aides were competent in responding to medical emergencies, including the use of emergency equipment and CPR. A resident with multiple serious conditions and a full code status experienced a respiratory emergency and fall, but staff did not initiate CPR or use an Ambu bag due to lack of training and uncertainty about equipment location. Facility records showed no regular training, no tracking of CPR certification, and no code team assignments, resulting in an uncoordinated and inadequate emergency response.
A sealed bottle of liquid opioid pain medication prescribed for a resident was found opened and partially used, with no documentation of administration and no sign-out in the controlled medication log. Staff discovered the missing seal and a syringe with residue matching the medication, but were unable to determine who accessed the medication or how it was removed. The resident, who had multiple chronic conditions and moderate cognitive impairment, did not receive any doses of the medication, and the facility's policies did not adequately address misappropriation of property or secure handling of medication keys.
A resident in an LTC facility experienced a seizure due to missed doses of an anticonvulsant medication. The facility's policy required immediate documentation of medication administration, but an LPN signed off on a dose that was not administered, and another dose was not documented. Interviews revealed that improper documentation and communication between nurses led to the error, resulting in the resident not receiving two critical doses.
A resident with severe cognitive impairment did not receive pain medication according to professional standards due to a pharmacy packaging error. The pharmacy packaged two tablets per bubble pouch for a medication order requiring one tablet, and the bubble package was mislabeled as a scheduled medication. This led to confusion among nursing staff, with inconsistent practices in administering the medication.
The facility failed to maintain the dignity of two residents during care procedures. A resident with Alzheimer's received a wound dressing change in a public dining area, while another resident with severe cognitive impairment and impaired vision was given an insulin injection in a room with the door open and window blinds not closed, exposing them to public view. Both actions were acknowledged by staff as inappropriate and contrary to privacy and dignity policies.
A resident with coronary obstructive pulmonary disease and congestive heart failure was observed receiving oxygen therapy without a physician's order, contrary to facility policy. The resident was seen receiving oxygen at 5 liters per minute, and later at 4.5 liters per minute, via nasal cannula. Interviews with the RN and DON confirmed the absence of a physician's order for the oxygen administration, highlighting a failure to adhere to the requirement for medications to be administered only upon a written order.
A resident with Alzheimer's and diabetes received wound care at a dining table, violating infection control protocols. An LPN changed the dressing without a barrier, and the table was not disinfected afterward. Interviews with staff confirmed the inappropriateness of the location due to infection control and dignity concerns.
A resident with a history of transient cerebral ischemic attack was discharged without a required discharge summary, as per the facility's policy. The resident, who was cognitively intact and had a care plan supporting discharge to a non-nursing home level of care, did not receive the necessary discharge documentation and education. The DON confirmed the absence of a discharge summary, highlighting a deficiency in the discharge process.
Failure to Ensure Staff Competency in Medical Emergencies and Emergency Equipment Use
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care during medical emergencies, specifically in life-threatening situations requiring emergent intervention and the use of emergency medical equipment. The facility's assessment and competency evaluation processes did not include any plan or method to identify, assess, or evaluate staff competency in handling medical emergencies. Review of facility documents, including the education calendar, nurse skills checklists, and competency fair sheets, revealed no scheduled or documented training for CPR, BLS, mock codes, or emergency equipment usage. Additionally, job descriptions for nursing staff did not require CPR certification, and there was no system in place to track or verify which staff members held current certifications. A critical incident involved a resident with multiple complex diagnoses, including congestive heart failure, COPD, and acute kidney failure, who was admitted for ongoing care of an unstable condition and had a documented full code status. During a medical emergency, the resident experienced severe shortness of breath and subsequently suffered a fall with a head injury. Staff responses were delayed and uncoordinated; LPNs on the scene did not initiate CPR or use available emergency equipment such as an Ambu bag, citing uncertainty about equipment location and lack of training. Interviews with staff revealed that not all nurses were CPR certified, some were unaware of the location or existence of emergency equipment, and no code team assignments or mock code drills had been conducted. The facility's policies required CPR/BLS training and the maintenance of emergency equipment, but these were not implemented in practice. Further interviews with facility leadership, including the DON, Administrator, and Medical Director, confirmed that there was no systematic approach to ensuring staff competency in emergency response. The facility did not maintain a list of staff with current CPR certification, did not assign code teams or designate responsibilities during shifts, and did not provide staff with quick-reference materials for emergency procedures. The lack of accessible emergency equipment and absence of regular training or drills contributed to staff uncertainty and inadequate response during the resident's medical emergency.
Failure to Secure and Account for Controlled Medication
Penalty
Summary
The facility failed to maintain the integrity and security of a sealed controlled medication prescribed for a resident. A bottle of liquid opioid pain medication, which was supposed to be sealed and stored securely by staff, was found opened with part of its contents missing. The medication had been received from the pharmacy in a sealed container and was stored in its original packaging along with a syringe. No doses of the medication were documented as administered to the resident, and the medication administration record and controlled medication log both showed zero doses given. Staff interviews revealed that the seal on the medication bottle was missing, and a syringe with blue liquid residue matching the medication was found inside the box. The facility's Director of Nursing (DON) and LPNs confirmed that the medication had not been signed out or administered, and the missing seal could not be located. The DON determined that approximately 3ml of the opioid medication was unaccounted for. The facility's policies required medications to be stored in their original containers and locked compartments, but there was a lack of clear procedures regarding the handling of keys during staff breaks, and the policy on abuse and neglect did not specifically address misappropriation of property. The resident involved had multiple chronic conditions, including moderate cognitive impairment, and was on hospice care with an order for the opioid medication as needed for pain or shortness of breath. Despite the medication being prescribed and available, it was not administered, and the missing medication was not accounted for through proper documentation or investigation. The incident was reported, and staff drug testing was conducted, but the facility was unable to determine who accessed the medication or how the seal was broken.
Medication Administration Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the case of Resident #1. The facility's policy required that all medications administered to a resident be documented on the Medication Administration Record (MAR) immediately after administration. However, it was found that the 8:00 AM dose of an anticonvulsant medication on 08/25/2024 was signed off by LPN #3 but not actually administered, as there was no record of the medication being signed out in the narcotic book. Additionally, the 6:00 PM dose on 08/27/2024 was not signed off as administered. This lapse in medication administration led to Resident #1 experiencing seizure-like activity, necessitating emergency medical intervention. Interviews with the Director of Nursing (DON) and LPN #3 revealed that the medication errors were likely due to improper documentation practices and a lack of communication between nurses. The DON explained that nurses sometimes documented medications for each other, leading to confusion and missed doses. LPN #3 admitted to possibly documenting the medication without administering it, and there were no discrepancies noted in the narcotic counts, indicating the medication was not pulled. As a result, Resident #1 did not receive two doses of the anticonvulsant medication, which was crucial for controlling seizures, as confirmed by the hospital records following the incident.
Medication Dispensing Error Due to Mislabeling and Packaging
Penalty
Summary
The facility failed to dispense a pharmacy bubble packaged pain medication according to professional standards for a resident with severe cognitive impairment and multiple diagnoses, including dementia and osteoarthritis. During a medication administration pass, an LPN discovered that the pharmacy had packaged two tablets in each bubble pouch for a medication order that required only one tablet. The LPN attempted to contact the pharmacy to investigate the discrepancy but was initially unsuccessful. The resident's care plan indicated a risk for pain, and the physician's orders specified a scheduled dose of 325mg every 12 hours and an as-needed dose of 650mg every 4 hours. However, the medication administration record showed that only the scheduled doses were administered, and no as-needed doses were given. Further investigation revealed that the bubble package was mislabeled with a blue dot, indicating a scheduled medication, when it was actually for the as-needed order. The Director of Nursing confirmed that nurses might have been using a stock bottle for the scheduled dose. Interviews with other LPNs revealed inconsistent practices, with some leaving one tablet in the open bubble package for the next shift, while others wasted the second tablet. The packaging error and mislabeling led to confusion among the nursing staff, potentially risking medication errors.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of Resident #42 during wound care. The resident, who had severe cognitive impairment due to Alzheimer's Disease, was observed receiving a dressing change for a skin tear on the left forearm in the dining room, where other residents were present. This action was contrary to the facility's policy on maintaining privacy and dignity during care, as acknowledged by the LPN involved, who admitted that the dressing should not have been changed in a public area. Similarly, the facility did not ensure the dignity of Resident #11 during insulin administration. The resident, who also had severe cognitive impairment and impaired vision, was given an insulin injection in their room with the door open and the window blinds not closed, exposing the resident to the view of others in the dining room and the parking lot. The LPN administering the injection acknowledged that privacy should have been provided. The Infection Preventionist and the Director of Nursing confirmed that such actions were inappropriate and violated the residents' right to dignity and privacy.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility failed to ensure that oxygen was administered only when ordered by a physician, which could potentially lead to respiratory complications for a resident. The resident, who was admitted with coronary obstructive pulmonary disease and congestive heart failure, was observed receiving oxygen therapy without a physician's order. The facility's policy requires medications, including oxygen, to be administered only upon a written order from a licensed prescriber. However, a review of the resident's records revealed no such order for oxygen therapy. During observations, the resident was seen receiving oxygen at 5 liters per minute, and later at 4.5 liters per minute, via nasal cannula. Interviews with the RN and the DON confirmed that there was no physician's order for the oxygen administration. The RN acknowledged that oxygen should be administered according to a physician's order, and the DON confirmed that a resident should not receive oxygen without an order. Despite the care plan allowing for hospice nurse intervention, there was no documentation of a physician's order for the oxygen therapy being administered.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for a resident with Alzheimer's disease and type 2 diabetes. The resident, who had severe cognitive impairment and was at risk for skin breakdown, was observed receiving wound care at a dining table in the facility's dining room. The Licensed Practical Nurse (LPN) applied a dressing to the resident's left arm without using a barrier for supplies, and the table was not cleaned or disinfected after the procedure. This action was contrary to the facility's infection control goals, which emphasize minimizing the transmission of pathogens and disinfecting environmental surfaces. Interviews with the LPN, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the dressing change should not have occurred in the dining room due to infection control and dignity concerns. The IP and DON highlighted that performing wound care in a dining area could lead to contamination of the wound and the dining environment. The resident's family member also noted that the resident was on a blood thinner and had a tendency to pick at scabs, which could exacerbate the risk of infection. The facility's failure to adhere to proper infection control protocols during wound care was identified as a deficiency.
Failure to Provide Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a discharge summary for a resident, identified as Resident #45, at the time of a planned discharge. According to the facility's policy titled 'Transfer or Discharge, Preparing a Resident for,' a post-discharge plan should be developed and reviewed with the resident or their family at least 24 hours before discharge. The policy also states that nursing services are responsible for preparing the discharge summary and post-discharge plan, obtaining discharge orders, and providing the resident or their representative with the required documents. However, during an interview, the Director of Nursing (DON) revealed that there was no discharge summary prepared for Resident #45, indicating a lapse in following the facility's discharge procedures. Resident #45 was admitted with a diagnosis of transient cerebral ischemic attack and had a BIMS score indicating cognitive intactness. The resident had a care plan that included a desire to be discharged to a non-nursing home level of care, with family support for the discharge. Despite this, there was no active discharge planning for the resident to return to the community. A physician's order allowed for a trial discharge home, but the necessary discharge summary and educational materials were not provided to the resident or caregiver, as confirmed by the social worker. This oversight in documentation and communication represents a deficiency in the facility's discharge process.
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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 Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fayetteville Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 7 | 0 |
| North Hills Life Care And Rehab | 1.5 mi | ★★★★★ | 1 | 0 |
| Edgewood Health And Rehab | 2.5 mi | ★★★★★ | 0 | 0 |
| Arkansas Veterans Home At Fayetteville | 3.1 mi | ★★★★★ | 0 | 0 |
| Westwood Health And Rehab, Inc | 4 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.