Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Desoto Retirement & Rehab Ctr, Llc during CMS and state inspections, most recent first.
A CNA verbally abused a resident with multiple medical conditions by using loud, profane, and derogatory language while assisting with mobility. The incident was captured on video by the resident's family and later confirmed through investigation. Although the resident did not report feeling abused, the CNA's conduct met the facility's definition of verbal abuse, and the facility failed to protect the resident's right to be free from such treatment.
A resident was subjected to verbal abuse by a CNA, as evidenced by a video provided by the resident's sister. Although the incident was promptly brought to the attention of facility leadership and an investigation was initiated, the required report to the state agency was not submitted within the mandated two-hour window, resulting in noncompliance with reporting requirements.
The facility failed to accurately document the use of bedrails in the MDS assessments for three residents, despite physician orders indicating their necessity for bed mobility assistance. This discrepancy was confirmed by the MDS coordinator, highlighting a deficiency in the facility's assessment process.
The facility failed to develop comprehensive care plans for two residents, omitting critical interventions for conditions such as diabetes, hypertension, and impaired mobility. This oversight was acknowledged by the MDS coordinator, indicating a lack of individualized care planning.
The facility failed to provide necessary nail care for two residents, leading to deficiencies in personal hygiene. One resident with multiple health issues had untrimmed fingernails with a brown substance, while another resident with a history of fractures and muscle weakness had long toenails. Both residents expressed dissatisfaction with their nail care, and staff confirmed the need for trimming, indicating a lapse in the facility's nail care policy.
A resident with a contracted right hand did not receive care according to physician orders, as the palm protector was not used, and the resident's fingernails were long and discolored. The resident sometimes refused the palm protector, but these refusals were not documented, and the care plan was not updated to reflect the resident's condition. An LPN was unable to locate the palm protector and acknowledged the need for care plan updates.
The facility failed to ensure proper use and maintenance of bed rails for two residents, lacking safety assessments and informed consent. One resident with multiple health issues had bilateral bed rails without a care plan or consent, while another with a fracture and muscle weakness had quarter side rails without a risk assessment or consent. The DON confirmed these deficiencies.
The facility failed to ensure proper medication administration and storage for two residents. An LPN documented administering insulin before it was given, and another LPN stored an inhaler in a resident's room without an order for self-administration. The DON confirmed these actions were against protocol.
The facility failed to provide current pharmaceutical services by having expired medications on two medication carts. Observations revealed that Vitamin D 25 mcg with a best used by date of January 2025 was available on both carts. LPNs confirmed the medications were expired, and the DON reported that carts should be checked monthly to discard expired medications.
A facility failed to follow infection control practices during incontinence care for a resident with cognitive and physical impairments. A CNA placed soiled items on the resident's overbed table and floor, and did not change gloves before touching surfaces, risking cross-contamination. Additionally, a water cooler was improperly stored in a resident's room instead of the hallway, as confirmed by the DON.
A facility failed to transmit a completed resident's assessment within the required 7-day period. The resident, admitted with conditions such as hypertensive heart disease and obesity, had an MDS assessment marked as in progress. The MDS coordinator acknowledged the assessment was completed but not transmitted as required.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple complex diagnoses, including malnutrition, anxiety, schizophrenia, dementia, and gastrostomy status. The MDS coordinator confirmed the oversight during an interview.
A resident with COPD was found to have an unclean oxygen concentrator filter, contrary to the facility's guidelines requiring weekly cleaning. Observations showed the resident using continuous oxygen with a filter containing fluffy gray particles. Interviews with an LPN and the DON confirmed the oversight.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbal abuse toward a resident who had multiple complex medical conditions, including cerebral infarction, stroke, peripheral vascular disease, diabetes, heart disease, COPD, kidney failure, and dementia with behavioral disturbances. The resident was cognitively intact, required partial to moderate assistance with mobility and transfers, and had documented impairments in range of motion. The incident took place when the CNA entered the resident's room and used loud, profane, and derogatory language, instructing the resident to get up off the floor and onto the bed in a manner that was both forceful and inappropriate. The CNA's statements included explicit language and commands, and the interaction was captured on video by the resident's family, who had installed a camera in the room. The CNA admitted to making inappropriate comments out of frustration, acknowledging that her language and behavior were not suitable while caring for the resident. The video evidence confirmed that the CNA used profane language and spoke loudly and disparagingly in the presence of the resident. Although the resident did not report feeling disrespected or abused during subsequent interviews, the CNA's conduct met the facility's definition of verbal abuse, which includes the use of oral or gestured communication that is disparaging or derogatory, regardless of the resident's perception or response. The incident was initially discovered by the resident's family, who shared the video with facility administration. The investigation revealed that the CNA had been allowed to return to work after an initial suspension, and the full extent of the incident was not immediately recognized by all facility leadership. The Director of Nursing (DON) and former administrator did not view the complete video until later, and the investigation was not thoroughly conducted at first. The deficiency was cited based on the failure to protect the resident's right to be free from verbal abuse by a staff member.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to comply with required reporting procedures for suspected abuse, specifically in the case of a resident who was subjected to verbal abuse by a CNA. According to the facility's policy, allegations of abuse must be reported to the state survey agency and other authorities within two hours of the allegation being made. In this incident, the resident's sister provided video evidence of the CNA using derogatory and profane language toward the resident. The incident was brought to the attention of the facility's former administrator and DON, who acknowledged the unprofessional conduct and initiated an investigation, including suspending the CNA. Despite being made aware of the allegation on the same day it was reported by the resident's sister, the facility did not enter the required report into the Self-Reported Incident Management System (SIMS) until several days later, well beyond the mandated two-hour timeframe. The DON confirmed that the report should have been submitted promptly on the day the allegation was made, but it was not entered until a week later. This delay constituted a failure to meet state law and facility policy requirements for timely reporting of abuse allegations.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of three residents during the observation period. Specifically, the MDS assessments for these residents did not accurately document the use of bedrails, which were ordered by physicians to assist with bed mobility. Resident #5, who had severe mental cognition impairment and required extensive assistance for bed mobility, had physician orders for side rails, but the MDS did not indicate their use. Similarly, Resident #21, with moderate cognitive impairment and dependence on assistance for toileting and hygiene, had orders for bedrails, yet the MDS failed to reflect this. Resident #50, with moderate cognitive impairment and requiring assistance for bed mobility and transfers, also had orders for enablers to aid in bed mobility, but the MDS did not document their use. During an interview, the MDS coordinator confirmed that the MDS assessments for these residents did not include the use of bedrails as indicated in the physician orders. This discrepancy highlights a failure in accurately coding the MDS, which is crucial for ensuring that residents' needs and care requirements are properly documented and addressed. The oversight in accurately reflecting the use of bedrails in the MDS assessments for these residents represents a deficiency in the facility's assessment process.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #28's care plan did not include necessary interventions for several conditions, including oxygen therapy, type 2 diabetes mellitus, hypertension, activities of daily living self-care deficit, impaired mobility due to amputation, anticoagulant therapy, unsafe smoking habits, and diuretic use. This oversight was acknowledged by S4 MDS during an interview, indicating a lack of comprehensive planning for the resident's complex medical needs. Similarly, Resident #118's care plan was incomplete, failing to address critical issues such as nutrition, hypertension, insomnia, and anemia. The absence of these elements in the care plan was also confirmed by S4 MDS, highlighting a significant gap in the facility's approach to individualized care planning. These deficiencies suggest a systemic issue in the facility's ability to create and implement effective care plans tailored to the specific needs of its residents.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary nail care services to two residents, leading to deficiencies in personal hygiene and grooming. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was found to have untrimmed fingernails with a brown substance underneath. This resident, with moderately impaired cognition, required assistance with activities of daily living, including grooming. Despite the resident's expressed desire to have their nails trimmed, the facility did not ensure this care was provided, as confirmed by the Director of Nursing. Similarly, Resident #63, who has a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with long toenails that had grown over the nail bed. This resident, with intact cognition, also expressed dissatisfaction with the length of their toenails. The facility's failure to provide timely nail care was confirmed by an LPN, who acknowledged the need for the resident's toenails to be trimmed. These observations indicate a lapse in adhering to the facility's nail care policy, which outlines regular nail maintenance as part of the residents' care plans.
Failure to Follow Physician Orders for Palm Protector
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a contracted right hand, as per physician orders and professional standards of practice. The resident, who has diagnoses including end-stage renal disease, hypertensive heart disease, and major depressive disorder, was ordered to use a palm protector on the right hand to prevent complications such as skin breakdown. However, observations revealed that the palm protector was not in use, and the resident's hand was tightly closed with long, discolored fingernails that had grown over the nail bed, potentially leading to skin integrity issues. Interviews and record reviews indicated that the resident sometimes refused the palm protector, but there was no documentation of these refusals or attempts to apply the protector. The resident's care plan and MDS did not accurately reflect the resident's limitations in range of motion or refusals of care. Additionally, the LPN was unable to locate the palm protector and acknowledged the need for updated care planning based on the resident's refusals and the condition of the resident's fingernails, which could contribute to skin breakdown.
Failure to Ensure Proper Use and Consent for Bed Rails
Penalty
Summary
The facility failed to ensure the correct use and maintenance of bed rails for two residents, leading to deficiencies in safety assessments and informed consent. Resident #43, who has a history of cerebrovascular disease, heart failure, epilepsy, chronic atrial fibrillation, and end-stage renal disease, was observed with bilateral bed rails without a documented care plan addressing bed rail use or a signed consent for their installation. Despite having moderately impaired cognition and requiring two-person assistance for bed mobility, there was no evidence of a risk assessment for entrapment or a discussion of risks and benefits with the resident or their representative. Similarly, Resident #63, with a history of a wedge compression fracture, lack of coordination, and generalized muscle weakness, was observed with quarter side rails raised on both sides of the bed. Although this resident had intact cognition and required assistance with bed mobility, the facility failed to document a care plan specific to the use of quarter side rails and did not obtain a signed consent. Additionally, there was no assessment conducted for the risk of entrapment prior to the installation of the bed rails. The Director of Nurses confirmed these deficiencies during an interview.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for two residents, leading to deficiencies in nursing services. For Resident #24, an LPN administered Sucralfate but prematurely documented the administration of Humalog, which was not given at the time of documentation. The LPN acknowledged that the Humalog was due later and had not been administered, despite the resident's blood sugar being 310 earlier, indicating a need for the medication closer to meal time. The Director of Nursing confirmed that medications should not be documented in the electronic medication administration record until they are actually administered. For Resident #26, an LPN was observed without the resident's prescribed Fluticasone-Salmeterol Inhaler on the medication cart, finding it instead in the resident's room. The LPN confirmed that the inhaler should have been stored on the medication cart, as the resident did not have an order for self-administration. The Director of Nursing reiterated that the medication should not have been kept in the resident's room, highlighting a failure in proper medication storage and administration procedures.
Expired Medications Found on Facility's Medication Carts
Penalty
Summary
The facility failed to provide current pharmaceutical services to meet the needs of each resident by having expired medications available for use on two medication carts. During an observation of Medication Cart 1 for Hall 1, it was found that Vitamin D 25 mcg had a best used by date of January 2025, which was confirmed by an LPN to be expired and should not have been available. Similarly, an observation of the Medication Cart for Hall 2 revealed the same expired Vitamin D 25 mcg, which was also confirmed by another LPN. The Director of Nursing reported that medication carts should have been checked at the end of each month to discard expired medications, indicating a lapse in the facility's medication management process.
Infection Control Lapses in Incontinence Care and Equipment Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident with moderately impaired cognition and physical limitations due to macular degeneration and hemiplegia. During an observation, a CNA was seen retrieving towels and a draw pad from a linen cart and placing them on the resident's overbed table along with personal items. The CNA used wet towels to perform perineal care and placed the used towels back on the overbed table. The CNA also placed a used incontinence brief on the floor and reused towels to clean the resident's buttocks and rectal area. After completing the care, the CNA disposed of the soiled items on the floor and touched various surfaces, including the bed remote and door knob, without changing gloves, leading to potential cross-contamination. Additionally, the facility failed to store patient equipment properly, as observed with a water cooler containing ice for resident drinking being stored in an occupied resident's room on a secured unit. A CNA confirmed the storage location and reported no alternative storage space on the unit. The Director of Nursing acknowledged that the water cooler should be stored in the hallway rather than in a resident's room, indicating a lapse in maintaining a sanitary environment for residents.
Failure to Transmit Resident Assessment Timely
Penalty
Summary
The facility failed to transmit a completed resident's assessment within the required 7-day period for one resident out of 31 sampled. The resident, who was admitted with diagnoses including hypertensive heart disease without heart failure, obesity, anemia, and insomnia, had an MDS assessment marked as in progress. During an interview, the MDS coordinator acknowledged that the assessment was completed but had not been transmitted as required.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident. The resident was admitted with multiple diagnoses, including unspecified protein-calorie malnutrition, generalized anxiety disorder, undifferentiated schizophrenia, unspecified dementia with agitation, anorexia, other specified extrapyramidal and movement disorders, major depressive disorder, impulsive disorder, and gastrostomy status. A review of the resident's medical records revealed that a baseline care plan was not completed upon admission. During an interview, the MDS coordinator acknowledged that the baseline care plan was not developed as required.
Failure to Clean Oxygen Concentrator Filter
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with chronic obstructive pulmonary disease (COPD). The deficiency was identified when the oxygen concentrator filter for the resident was observed to have a moderate amount of fluffy gray particles, indicating it had not been cleaned as required. The facility's Respiratory Equipment - Infection Control Guidelines specify that housekeeping is responsible for cleaning oxygen concentrator filters weekly, which was not adhered to in this case. The resident, who was admitted with a diagnosis of COPD, had a physician's order for oxygen at 2 liters per nasal cannula as needed for shortness of breath or when oxygen saturation was below 90%. Observations on multiple occasions revealed the resident wearing continuous oxygen, with the concentrator filter remaining uncleaned. Interviews with the LPN and the Director of Nursing confirmed the oversight, acknowledging that the filter was dirty and should have been cleaned according to the facility's guidelines.
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Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mansfield Nursing Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Green Meadow Haven | 21.7 mi | ★★★★★ | 6 | 0 |
| Heritage Manor South | 25.2 mi | ★★★★★ | 4 | 0 |
| Village Health Care At The Glen | 25.4 mi | ★★★★★ | 3 | 0 |
| Live Oak | 25.6 mi | ★★★★★ | 0 | 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.