Inspection Reports for
Southern Trace Rehabilitation and Care Center
22515 Interstate 30, Bryant, AR, 72022
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as an annual survey of Southern Trace Rehabilitation and Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
The inspection was conducted due to complaints regarding resident-to-resident abuse incidents involving Resident #5 and other residents, focusing on ensuring residents were free from abuse.
Complaint Details
The complaint investigation found substantiated incidents of resident-to-resident abuse involving Resident #5 as the aggressor against Residents #4, #9, #13, and #14. Several physical aggression incidents were documented, including pushing, striking, and pulling residents, resulting in injuries such as a lumbar compression fracture. The facility did not report some incidents to the Office of Long-Term Care due to no injuries being recorded.
Findings
The facility failed to prevent resident-to-resident abuse for 4 of 14 sampled residents, with Resident #5 identified as the physical aggressor in multiple incidents causing actual harm. The facility lacked effective behavior monitoring and did not report some incidents due to absence of injuries, despite documented physical aggression and resulting injuries including a compression fracture.
Deficiencies (1)
Failure to protect residents from resident-to-resident abuse resulting in actual harm.
Report Facts
Residents sampled for abuse review: 14
Residents affected by abuse: 4
Physical aggression incidents initiated by Resident #5: 7
BIMS score of Resident #5: 3
BIMS score of Resident #4: 9
BIMS score of Resident #9: 7
BIMS score of Resident #13: 3
BIMS score of Resident #14: 0
Pain level of Resident #4: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Witnessed Resident #4 yelling and falling after being pushed by Resident #5 |
| Minimum Data Set Coordinator | Licensed Practical Nurse | Provided list of Resident #5's physical aggression incidents and described behavior |
| Administrator | Provided information about incident reporting practices and Quality Assurance reviews | |
| Certified Nursing Assistant #3 | CNA | Reported Resident #5's behavior and sleep issues prior to incidents |
| Certified Nursing Assistant #5 | CNA | Provided witness statement regarding incidents |
| Licensed Practical Nurse #4 | LPN | Reported involvement in care after Resident #4 was pushed and x-ray was obtained |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow infection prevention and control protocols, specifically related to contact isolation precautions for Resident #5.
Complaint Details
The complaint investigation found that staff did not wear gowns during care and that isolation signage was missing or not properly placed after Resident #5 was moved rooms. Interviews with staff including CNAs, Infection Control Nurse, Treatment Nurse, and Director of Nursing confirmed these lapses. Resident #5 had been on contact isolation for ESBL since admission.
Findings
The facility failed to ensure staff wore isolation gowns when providing care to Resident #5 who was on contact isolation, and failed to place contact isolation signage outside the resident's room. This failure posed a potential risk for spreading infections within the facility.
Deficiencies (2)
Failure to ensure staff wore an isolation gown when providing care for Resident #5 on contact isolation.
Failure to ensure a contact isolation sign was placed outside Resident #5's door to alert staff to apply PPE before providing care.
Report Facts
Date of infection surveillance report: Oct 16, 2024
Date of physician order: Oct 28, 2024
Assessment Reference Date: Oct 18, 2024
Date Resident #5 moved rooms: Nov 15, 2024
Inspection Report
Routine
Deficiencies: 8
Date: May 31, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident privacy, care planning, environmental safety, food service, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, inadequate care planning for residents on diuretics and enteral feeding, environmental hazards such as foreign substances in resident rooms, improper food preparation and handling, and lapses in infection prevention practices including hand hygiene and use of personal protective equipment. Several policies were noted as absent.
Deficiencies (8)
Failed to ensure privacy for 2 residents due to a door that does not stay shut and improper use of privacy curtains.
Failed to ensure operational air conditioner for 1 resident to promote a comfortable environment.
Failed to implement a comprehensive care plan addressing diuretic therapy for 1 resident.
Failed to revise care plan to reflect changes in enteral feeding for 1 resident.
Failed to ensure foreign substances were not left in a resident's room and failed to ensure licensed nurse placed enteral feeding pump on hold prior to laying resident flat.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency for residents on pureed diets.
Failed to follow sanitary procedures in food service including uncovered food transport, uncovered beverages, improper hand hygiene, and unclean kitchen environment.
Failed to ensure hand hygiene during incontinence care and failed to don appropriate PPE for resident on enhanced barrier precautions; also failed to maintain clean and sanitary environment.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 82
Residents affected: 13
Total census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nursing Assistant | Observed attempting to close Resident #21's door and using privacy curtain |
| CNA #6 | Certified Nursing Assistant | Confirmed privacy curtain use and reported door repair history |
| CNA #7 | Certified Nursing Assistant | Observed providing incontinence care without gown and improper enteral feeding pump handling |
| CNA #8 | Certified Nursing Assistant | Observed providing incontinence care without gown |
| ADON #1 | Assistant Director of Nursing | Provided information on privacy, maintenance reporting, and infection control policies |
| ADON #2 | Assistant Director of Nursing | Provided information on privacy, maintenance reporting, and infection control policies |
| DON | Director of Nursing | Voiced concerns about privacy, care plans, enteral feeding, and infection control policies |
| Dietary Aide #20 | Dietary Aide | Observed preparing pureed food |
| Dietary Aide #16 | Dietary Aide | Observed improper glove use and handling of beverages |
| Dietary Manager | Dietary Manager | Observed uncovered food transport and kitchen sanitation issues |
| Housekeeping Supervisor #17 | Housekeeping Supervisor | Discussed cleaning responsibilities and importance of sanitation |
| Housekeeping Staff #18 | Housekeeping Staff | Responsible for cleaning resident rooms and bathrooms |
| Housekeeping Staff #19 | Housekeeping Staff | Responsible for cleaning resident rooms and bathrooms |
Inspection Report
Routine
Deficiencies: 3
Date: May 31, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols, including hand hygiene, use of personal protective equipment, and environmental cleanliness.
Findings
The facility failed to ensure proper hand hygiene during incontinence care, appropriate use of personal protective equipment for residents on enhanced barrier precautions, and maintaining a clean and sanitary environment, including feces contamination in resident rooms and bathrooms.
Deficiencies (3)
Failure to perform hand hygiene during incontinence care for Resident #46, risking cross contamination.
Failure to ensure staff donned appropriate personal protective equipment for Resident #57 on enhanced barrier precautions.
Failure to maintain a clean and sanitary environment, including feces on walls, floors, and toilets in resident rooms.
Report Facts
Residents sampled: 13
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #12 | Certified Nursing Assistant | Observed failing to perform hand hygiene during incontinence care |
| CNA #7 | Certified Nursing Assistant | Observed not wearing gown during care of Resident #57 |
| CNA #8 | Certified Nursing Assistant | Observed not wearing gown during care of Resident #57 |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Interviewed regarding proper hand hygiene and PPE use |
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Interviewed regarding proper hand hygiene and PPE use |
| Director of Nursing | Director of Nursing | Confirmed PPE requirements and lack of policy on Enhanced Barrier Precautions |
| Housekeeping Staff #18 | Housekeeping Staff | Interviewed about cleaning responsibilities and importance |
| Housekeeping Supervisor #17 | Housekeeping Supervisor | Interviewed about cleaning responsibilities and infection control |
| Housekeeping Staff #19 | Housekeeping Staff | Interviewed about cleaning responsibilities and infection control |
| Administrator | Administrator | Stated facility did not have a cleaning policy |
Inspection Report
Deficiencies: 1
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing appropriate care for residents who are continent or incontinent of bowel/bladder, including appropriate catheter care and prevention of urinary tract infections.
Findings
The facility failed to provide appropriately sized briefs for three sampled residents who were incontinent and used briefs, resulting in residents wearing briefs that were too small or improperly fastened. Staff reported frequent shortages of large and extra-large briefs, leading to use of smaller sizes that caused discomfort and skin irritation.
Deficiencies (1)
Failed to provide appropriate size briefs for 3 sampled residents who were incontinent and used briefs.
Report Facts
Residents affected: 3
Inspection Report
Routine
Census: 87
Deficiencies: 9
Date: Jun 30, 2023
Visit Reason
Routine inspection of Southern Trace Rehabilitation and Care Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dining assistance, incomplete and improperly implemented care plans, inadequate nail care, improper bed fit for a resident, failure to maintain beds at lowest position for fall risk residents, inadequate supervision in smoking areas, unsanitary food handling practices, malfunctioning resident care equipment, missing bathroom call light cords, and failure to maintain a home-like environment such as making beds.
Deficiencies (9)
Failed to provide dining assistance in a manner that protected and promoted the dignity of residents.
Failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions.
Failed to ensure nail care was provided for a resident who relied on the facility for assistance.
Failed to provide a bed that properly fit a resident, causing feet to protrude from the bed.
Failed to follow care planned intervention of maintaining a resident's bed at the lowest position for fall risk and failed to ensure adequate supervision while smoking.
Failed to ensure sanitary procedures were followed when serving food to prevent potential foodborne illness.
Failed to maintain essential resident care equipment in safe operating condition, including damaged air conditioning units, unsecured toilets, and dirty fans.
Missing bathroom call light pull cords, compromising resident safety.
Failed to ensure a home-like environment by not making a resident's bed as requested.
Report Facts
Resident census: 87
Residents sampled: 20
Residents affected: 85
Resident height: 72
Resident bed mattress length: 70
Fall risk score: 14
Elopement risk score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Observed assisting residents with dining in a manner not promoting dignity | |
| Director of Nursing (DON) | Director of Nursing | Provided documents and answered questions about care plans and facility policies |
| Assistant Director of Nursing (ADON) #1 | Assistant Director of Nursing | Interviewed regarding care plans, nail care, equipment issues, and supervision |
| Certified Nursing Assistant (CNA) #1 | Observed redirecting resident and commented on supervision in smoking area | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Interviewed about diversion interventions for wandering residents |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Interviewed about nail care responsibilities and resident bed status |
| Certified Nursing Assistant (CNA) #6 | Observed serving food improperly and bed making | |
| Dietary Employee (DE) #1 | Observed handling food and equipment unsanitarily | |
| Dietary Employee (DE) #2 | Observed handling food and equipment unsanitarily | |
| Dietary Employee (DE) #3 | Observed handling food and equipment unsanitarily | |
| Dietary Employee (DE) #4 | Observed handling food and equipment unsanitarily | |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about repairs and maintenance issues |
| Housekeeping Manager | Housekeeping Manager | Interviewed about cleaning and dust on fan |
| Administrator | Administrator | Interviewed about maintenance and safety issues |
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