Southern Trace Rehabilitation And Care Center

F-F600 indicated, Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, Level of Harm - Actual harm grabbing, shoving . The action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm . Having a mental disorder or cognitive impairment does not automatically preclude a resident Residents Affected - Few from engaging in deliberate or non-accidental actions.

8. A review of Resident #5's Care Plan Report indicated Resident #5 had the potential targeted behavior related to dementia, with the following interventions listed: Administer medications as ordered date initiated [DATE REDACTED], Anticipate resident's needs date initiated [DATE REDACTED], Identify times of day, places, circumstances, triggers, and what de-escalates behavior - date initiated [DATE REDACTED], Resident #5 has thicker accent and paces usually before behavior. Resident #5 behaviors are de-escalated by time outside and reggae music calms him date initiated [DATE REDACTED], when Resident #5 becomes agitated, attempt to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk away calmly and approach later, date initiated [DATE REDACTED]. Care Plan identified Resident #5 to have

a BIMS of 3. The Care Plan did not reflect any incidents this resident had during Resident #5's stay at the facility. Resident #5 exhibited aggressive behaviors toward Residents #9, #13, and #14 prior to the implementation of the behavior care plan being developed.

9. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE REDACTED], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. Resident #4 was identified to have disorganized or incoherent thinking. The MDS does not identify Resident #4 to have behavioral symptoms.

a. A review of Resident #4's physician orders dated [DATE REDACTED], identified Resident #4's diagnoses as Alzheimer's disease, cerebral infraction, dementia with other behavioral disturbance, type 2 diabetes mellitus, insomnia, atherosclerotic heart disease, osteo-arthritis, low back pain, pain in arm, intervertebral disc degeneration, lumbosacral region with discogenic back pain, and a wedge compression fracture of second lumbar vertebra initial encounter for closed fracture. An order on [DATE REDACTED] stated [analgesic opioid agonist medication name] 50 milligrams for other lower back pain.

b. A review of Resident #4's Care Plan Report indicated Resident #4 has requested that Cardiopulmonary Resuscitation (CPR) measures be performed, resident is a very sociable person, resident has a potential for Activities of Daily Living (ADL) self-care performance deficit secondary to dementia and Alzheimer's. Resident #4 was not care planned for behaviors.

10. A review of Resident #9's Care Plan Report revealed Resident #9 was not care planned for behavior issues.

a. A review of Resident #9's Medical Diagnosis report reflected the resident had diagnoses that included Alzheimer's disease, chronic kidney disease stage 3A, osteoarthritis of knee, pain to the right knee, sciatica, alcohol dependence induced persisting dementia, Wernicke's encephalopathy, and Raynaud's syndrome.

b. The quarterly MDS with an ARD of [DATE REDACTED], revealed Resident #9 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS did not identify Resident #9 to have behavioral symptoms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 045305 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 045305 B. Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Trace Rehabilitation and Care Center 22515 I 30 Bryant, AR 72022

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 11. A review of Resident #13's physician Order Summary Report reflected the resident had diagnoses that included dementia, with other behavioral disturbances, Alzheimer's disease, anxiety disorder, chronic pain, Level of Harm - Actual harm major depressive disorder, restlessness and agitation, and insomnia.

Residents Affected - Few a. The quarterly MDS with an ARD of [DATE REDACTED], revealed Resident #13 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS identified Resident #13 to sometimes have behavioral symptoms, inattention, difficulty focusing attention, disorganized thinking, disorganized physical behavioral symptoms and verbal behavioral symptoms.

12. A review of Resident #14's Care Plan Report indicated Resident #14 had the potential to be verbally aggressive related to cognition and cognitive status. Resident will often cry when upset. Date initiated [DATE REDACTED].

a. A review of Resident #14's Medical Diagnosis report reflected the resident had diagnoses that included dementia, with other behavioral disturbances, insomnia, atherosclerotic heart disease, restlessness and agitation, and palliative care.

b. The significant change MDS with an ARD of [DATE REDACTED], revealed Resident #14 had a BIMS score of 00, which indicated severe cognitive impairment. The MDS did not identify Resident #14 to have behavioral symptoms, inattention, difficulty focusing attention, disorganized thinking, disorganized, and altered level of consciousness, indicating behavior not exhibited.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 045305