Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Southern Trace Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with severe dementia repeatedly exhibited aggressive behavior towards other residents, resulting in physical abuse incidents. The facility failed to effectively monitor and address these behaviors, as the care plan was not adequately implemented or updated. Despite multiple incidents, the facility did not report all occurrences to the Office of Long-Term Care, and investigations were insufficient.
A facility failed to implement proper contact isolation precautions for a resident with multiple infections, including ESBL. Staff did not wear isolation gowns, and there was no contact isolation sign outside the resident's room. Interviews revealed staff were unaware of the need for gowns, and the isolation sign was not moved when the resident changed rooms. The resident confirmed that staff only began wearing gowns on the day of the surveyor's visit.
The facility failed to follow sanitary procedures when serving food, leading to potential foodborne illnesses. Observations included uncovered food transport, improper hand hygiene by CNAs, and unsanitary kitchen conditions. Multiple residents with severe cognitive impairments were affected.
The facility failed to ensure privacy for two residents. One resident's door did not stay shut, and staff used a privacy curtain to keep it closed, leaving a 4-foot open area. Another resident was exposed during incontinence care due to an open privacy curtain. The facility lacked a dignity policy.
The facility failed to prevent accident hazards by leaving a foreign substance in a resident's room and did not ensure proper handling of an enteral feeding pump for another resident, leading to potential ingestion and aspiration risks.
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, posing a risk to residents requiring pureed diets. Observations revealed that the pureed chicken and dumplings were thick and gooey, and the pureed cake was clumpy. Staff confirmed the inappropriate texture of the food.
The facility failed to ensure proper hand hygiene during incontinence care for a resident, did not use appropriate PPE for another resident requiring Enhanced Barrier Precautions, and did not maintain a clean and sanitary environment in a resident's room. Housekeeping staff acknowledged the presence of feces on the bathroom wall and floor, and the facility lacked a cleaning policy.
A resident with cerebral palsy and epilepsy experienced discomfort due to a broken air conditioner knob. The CNA was unaware of the reporting process, and the Maintenance Supervisor admitted to sometimes forgetting verbal repair requests. The maintenance binder did not list the issue, and ADONs were unsure if staff had been inserviced on the reporting procedure.
The facility failed to include diuretic therapy in a resident's care plan, despite the resident being prescribed Furosemide for edema. The omission was confirmed by the MDS Nurse and MDS Consultant, who acknowledged the importance of monitoring relevant labs to prevent falls and ensure comprehensive care.
The facility failed to update a resident's care plan to reflect a change from bolus to continuous enteral feeding, despite physician's orders and observations indicating the change. This oversight was confirmed by the MDS Nurse and DON, who acknowledged the potential impact on resident care.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by multiple incidents involving Resident #5 as the aggressor. Resident #5 exhibited physical aggression towards other residents, including shoving, striking, slapping, and pulling, resulting in distress and injury to the victims. These incidents were not effectively monitored or addressed by the facility, leading to repeated occurrences of abuse. Resident #5, who has severe dementia and other cognitive impairments, was involved in several aggressive incidents. Despite having a care plan that included interventions for potential aggressive behavior, the facility did not adequately implement or update the plan to prevent further incidents. The care plan lacked documentation of the incidents and did not reflect the resident's history of aggression, which contributed to the ongoing issue. The facility's response to these incidents was insufficient, as they did not report all occurrences to the Office of Long-Term Care, especially when no visible injuries were present. Interviews with staff revealed a lack of consistent monitoring and intervention strategies for Resident #5's behavior. The facility's failure to conduct thorough investigations and document findings in Quality Assurance meetings further exacerbated the situation, allowing the aggressive behavior to persist without appropriate corrective measures.
Failure to Implement Proper Contact Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for a resident on contact isolation. The resident, who had a diagnosis of elevated white blood cell count, sepsis, unspecified open wound, unstageable pressure ulcer, bacteremia, and ESBL, was not provided with appropriate isolation precautions. Staff members did not wear isolation gowns when providing care, and there was no contact isolation sign outside the resident's room to alert staff to apply PPE before providing care. Additionally, there were no PPE supplies or trash bins for disposing of used gowns near the resident's room. Interviews revealed that staff were unaware of the need for gowns and that the isolation sign was not moved when the resident changed rooms. The Infection Control Nurse and Treatment Nurse were not aware of the missing signage, and the Director of Nursing acknowledged the oversight. The resident confirmed that staff only began wearing gowns on the day of the surveyor's visit, indicating a lapse in infection control practices since the resident's admission.
Sanitary Procedures and Food Handling Deficiencies
Penalty
Summary
The facility failed to follow sanitary procedures when serving food to residents, which could potentially lead to foodborne illnesses. Observations included the Dietary Manager transporting an uncovered plate across the hall to another dining area and placing it on a table without the resident present. Additionally, a CNA was observed assisting a resident with eating without performing hand hygiene, and another CNA handled food and drink items for a resident without using hand sanitizer, despite acknowledging the risk of cross-contamination. These actions were observed during meal service and involved multiple residents with severe cognitive impairments and dependencies on assistance for daily activities. Further deficiencies were noted in the storage and handling of food items in the kitchen. Sheet pans containing biscuit dough were stacked improperly, leading to potential contamination. Various food items in the refrigerator were not labeled or dated, and some were exposed to potential contamination due to improper sealing. The kitchen environment itself was found to be unsanitary, with debris on the refrigerator seal, uncovered pitchers of beverages, and flies present in the kitchen. Dietary staff were also observed handling food and utensils without proper hand hygiene or protective coverings, further increasing the risk of contamination. The facility's kitchen and food storage areas were found to be in poor condition, with stained floors, an ice scoop improperly stored in an ice chest, and loose coffee filters in an open drawer. The refrigerator in the memory unit contained unlabeled and undated food and drink items. Additionally, a dietary aide was observed entering the kitchen without a hair covering and handling food items with contaminated gloves. These observations indicate a widespread issue with maintaining sanitary conditions and proper food handling practices in the facility, affecting the overall safety and quality of care for the residents.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure privacy for two residents, leading to a deficiency in promoting a dignified existence. For Resident #21, the door to the room did not stay shut, and staff resorted to jamming the privacy curtain in the door to keep it closed. This makeshift solution was observed by the surveyor, who noted that the privacy curtain had a 4-foot open area, exposing Resident #21, who was resting uncovered and wearing a brief. Despite staff acknowledging the importance of a functioning door and privacy curtain, they had not reported the door issue to maintenance. The Assistant Directors of Nursing confirmed that every resident should have a privacy curtain, a door that closes, and working window blinds for privacy, but the facility lacked a dignity policy. For Resident #57, who had multiple medical conditions including dysphagia, a pressure ulcer, and an indwelling catheter, the facility also failed to maintain privacy. The surveyor observed CNAs providing incontinence care to Resident #57 with the privacy curtain open, exposing the resident to the roommate and anyone entering the room. The CNAs confirmed awareness that the curtain should be pulled for privacy, and the Director of Nursing reiterated that the curtain should be pulled and the door closed during care. However, the facility did not have a policy on dignity or privacy, contributing to the deficiency.
Failure to Prevent Accident Hazards and Ensure Proper Enteral Feeding Procedures
Penalty
Summary
The facility failed to ensure foreign substances were not left in a resident's room, which could lead to possible ingestion and harm. Resident #46, who had diagnoses of chronic obstructive pulmonary disease, epilepsy, and dementia, was observed to have a cup containing a thick orange substance in their bathroom. The substance was initially thought to be juice but was later identified by an LPN as possibly soap. Both the LPN and the DON acknowledged the potential risk of someone drinking the unknown substance, but the facility did not have any policies to address this issue. Additionally, the facility failed to ensure proper handling of an enteral feeding pump for Resident #57, who had diagnoses of dysphagia, pressure ulcer, and required assistance with personal care. CNAs were observed laying the resident flat without placing the enteral feeding pump on hold, which led to the resident coughing and the pump displaying a hold error. The DON confirmed that the pump should be placed on hold by a licensed nurse to prevent aspiration, but the facility did not have a policy on enteral feeding, and an in-service on the matter was not provided as requested.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were blended to a smooth, lump-free consistency, which is necessary to minimize the risk of choking or other complications for residents requiring pureed diets. During observations, it was noted that the pureed chicken and dumplings were thick and gooey, and the pureed cake was clumpy and not smooth. The Dietary Aide added excessive thickener to the chicken dumplings, resulting in an inappropriate consistency. The Director of Nursing and several CNAs confirmed that the pureed food items were too textured and not suitable for residents on pureed diets. The Dietary Supervisor acknowledged that the pureed cake did not look smooth and that the pureed chicken and dumplings were too thick. The CNAs assisting residents in the dining room also described the pureed food items as thick and clumpy. These observations and interviews indicate that the facility did not properly prepare pureed food to meet the individual needs of residents requiring such diets, potentially affecting six residents who received pureed diets.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene during incontinence care for Resident #46, who had diagnoses including chronic obstructive pulmonary disease, epilepsy, and dementia. The resident required extensive assistance with toileting. During an observation, a CNA was seen using the same hand to wipe the resident's buttocks and perineal area, handle clean wipes, and adjust the resident's clothing without performing hand hygiene. The ADON confirmed that this practice was inappropriate and that staff should perform hand hygiene to prevent cross-contamination. The facility also failed to ensure that staff donned appropriate PPE for Resident #57, who required Enhanced Barrier Precautions due to chronic wounds, an indwelling catheter, and enteral feeding. During an observation, two CNAs provided incontinence care without wearing gowns, and soiled materials were placed on the floor. The DON confirmed that gowns and gloves should be worn to protect the resident from potential contamination and that soiled materials should not be placed on the floor. The facility did not have a policy on Enhanced Barrier Precautions. Additionally, the facility failed to maintain a clean and sanitary environment in a resident's room. Over several days, a brown substance identified as feces was observed on the bathroom wall and floor. Housekeeping staff acknowledged that it was their responsibility to clean and sanitize the room to prevent the spread of germs. The Administrator confirmed that the facility did not have a cleaning policy in place.
Failure to Ensure Operational Air Conditioner for Resident
Penalty
Summary
The facility failed to ensure that a resident with cerebral palsy and epilepsy had an operational air conditioner to promote a comfortable home environment. The resident, who scored a 5 on the Brief Interview for Mental Status indicating severe cognitive impairment, was observed by the surveyor to have a broken knob on the air conditioner unit. The resident expressed discomfort by waving hands near the face and saying 'Hot, hot.' The Certified Nursing Assistant (CNA) who was called over was unaware of the process to report maintenance issues but promised to notify maintenance immediately. The Maintenance Supervisor revealed that there is a maintenance binder at the nurse's station for documenting repair needs, but staff often verbally inform him of issues, which he sometimes forgets. The maintenance binder did not list the resident's room for any air conditioner issues. The Assistant Directors of Nursing (ADONs) confirmed the existence of the maintenance binder and stated that staff could either write in it or inform the charge nurse. However, they were unsure if staff had been inserviced on the reporting procedure, leading to the maintenance issue not being reported and addressed in a timely manner.
Failure to Implement Comprehensive Care Plan for Diuretic Therapy
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing diuretic therapy for a resident with diagnoses of cerebral infarction, depressive disorders, and urinary tract infection. The resident was prescribed Furosemide, a diuretic, to be taken daily for edema. However, the care plan did not include any information about the diuretic therapy. During an interview, the MDS Nurse and MDS Consultant confirmed that diuretics were not addressed in the care plan, despite being documented in the Minimum Data Set. The MDS Nurse emphasized the importance of including diuretic therapy in the care plan to monitor relevant labs, such as potassium levels, to prevent falls and ensure comprehensive care.
Failure to Revise Care Plan for Enteral Feeding
Penalty
Summary
The facility failed to revise the care plan for a resident with diagnoses of dysphagia oropharyngeal, dysphagia oral phase, and abnormal weight loss. The resident had a physician's order for enteral feeding every shift due to abnormal weight loss and was documented to have a feeding tube. The care plan initially indicated bolus feeding via PEG tube, but observations and interviews revealed that the resident was receiving continuous enteral feeding. Despite this change, the care plan was not updated to reflect the continuous feeding method, which could lead to staff not having the complete information and potentially administering the wrong feeding method. On multiple occasions, it was confirmed by the MDS Nurse and the Director of Nursing (DON) that the care plan had not been revised to align with the physician's orders. The MDS Nurse acknowledged that this oversight could negatively impact resident care. Additionally, the DON confirmed the discrepancy and noted that the facility did not have a policy on care plans, further contributing to the failure to update the resident's care plan appropriately.
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What surveyors actually found near you
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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 Bryant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Living Center At Stagecoach | 1.7 mi | ★★★★★ | 0 | 0 |
| Amberwood Health And Rehabilitation | 3.3 mi | ★★★★★ | 1 | 0 |
| Alcoa Pines Health And Rehabilitation | 4.6 mi | ★★★★★ | 0 | 0 |
| Heartland Rehabilitation And Care Center | 7 mi | ★★★★★ | 0 | 0 |
| Colonel Glenn Health And Rehab, Llc | 7.3 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.