BRYANT, AR - Federal inspectors cited Southern Trace Rehabilitation and Care Center following a complaint investigation that revealed the facility failed to protect residents from repeated physical assaults by another resident with severe cognitive impairment.
Resident with Dementia Assaults Three Others
The March 2025 inspection documented that Resident #5, who had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment, physically attacked three other residents during their stay at the facility. The assaults targeted Residents #9, #13, and #14, all of whom had documented diagnoses of dementia and Alzheimer's disease.
Federal regulations require nursing homes to ensure each resident receives care in a safe environment, free from abuse and neglect. The definition of abuse includes willful actions such as hitting, slapping, punching, choking, pinching, biting, kicking, and shoving. The regulation clarifies that the action itself must be deliberate or non-accidental, though the individual need not have intended to inflict injury.
The facility's failure to prevent these incidents resulted in actual harm to vulnerable residents, according to the inspection report.
Care Planning Failures Created Dangerous Environment
Inspectors found significant gaps in the facility's care planning that contributed to the unsafe conditions. While Resident #5 eventually received a behavior care plan, it was implemented only after the assaults on the three other residents had already occurred.
The care plan eventually developed for Resident #5 identified several behavioral triggers and de-escalation strategies. Staff documented that the resident had a thicker accent and typically paced before exhibiting aggressive behavior. The plan noted that Resident #5's behaviors could be de-escalated through time outside and reggae music. Interventions included identifying triggers, anticipating the resident's needs, and instructing staff to walk away calmly if the resident became aggressive.
However, the care plan made no reference to the previous incidents involving Residents #9, #13, and #14, representing a critical failure in documentation and risk assessment.
Victims Had Severe Cognitive Impairment
The three residents who experienced the assaults all had significant cognitive deficits that made them particularly vulnerable. Resident #9 had a BIMS score of 7, indicating severe cognitive impairment, with diagnoses including Alzheimer's disease, alcohol-induced dementia, and Wernicke's encephalopathy. Despite these conditions, Resident #9 had no behavior care plan addressing potential safety risks.
Resident #13 also had severe cognitive impairment with a BIMS score of 3 and was diagnosed with dementia, Alzheimer's disease, anxiety disorder, and major depressive disorder. The resident's assessment documented behavioral symptoms including restlessness, agitation, inattention, and disorganized thinking. Resident #13 exhibited both physical and verbal behavioral symptoms.
Resident #14 had the most severe cognitive impairment with a BIMS score of 0, along with diagnoses of dementia, insomnia, atherosclerotic heart disease, and restlessness. The resident's care plan noted a potential for verbal aggression and documented that the resident "will often cry when upset."
Medical Consequences of Inadequate Protection
Cognitively impaired residents face heightened vulnerability to injury from physical assaults. Individuals with dementia often cannot defend themselves, may not remember or be able to report incidents, and frequently have comorbid conditions that increase injury risk. Many residents with Alzheimer's disease take anticoagulant medications, making even minor physical contact potentially dangerous.
The presence of multiple residents with severe cognitive impairment and documented behavioral symptoms requires facilities to implement comprehensive monitoring systems. Standard practice includes regular behavioral assessments, environmental modifications to reduce triggers, adequate staffing ratios for supervision, and individualized care plans that address both potential aggressors and vulnerable residents.
When a resident exhibits aggressive behaviors toward others, facilities must immediately assess the situation and implement protective interventions. This may include increased supervision, room changes, behavioral interventions, medication review, or placement in a specialized dementia care unit.
Facility Required to Develop Corrective Action
The violation was cited under F600, the federal regulation requiring facilities to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. The citation documented actual harm to residents, affecting a few individuals within the facility.
Resident #4, though not directly mentioned as a victim of assault, was also identified in the inspection report as having moderate cognitive impairment with a BIMS score of 9 and diagnoses including Alzheimer's disease and dementia with behavioral disturbances. The resident had no behavior care plan despite these documented conditions.
The facility must submit a plan of correction detailing how it will prevent similar incidents. This typically includes staff training on recognizing behavioral triggers, implementing comprehensive behavior care plans before incidents occur, ensuring adequate supervision of residents with aggressive tendencies, and establishing protocols for protecting vulnerable residents.
The complete inspection report is available through the Centers for Medicare & Medicaid Services Nursing Home Compare website, where families can review detailed findings and the facility's response.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southern Trace Rehabilitation and Care Center from 2025-03-05 including all violations, facility responses, and corrective action plans.
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