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 Baisch Nursing Center during CMS and state inspections, most recent first.
The facility was found to have multiple environmental deficiencies, including a strong urine smell near the nurses' station and damaged door casings and ceiling tiles throughout the building. Interviews revealed that while maintenance is conducted regularly, there is no formal log for immediate repairs, and replacement materials are currently unavailable.
The facility failed to provide written notifications to residents and/or their representatives for hospital transfers, as required by policy. Interviews revealed that the practice was to notify families by phone, contrary to the policy. The deficiency was identified for six residents, with no documentation of written notifications found in their records.
The facility failed to provide written information about the bed hold policy to residents or their representatives during hospital transfers. Six residents were affected, with staff signing policies on behalf of residents unable to sign, and notifying families by phone instead of in writing. The ADON and other staff confirmed these practices, which did not meet the facility's policy expectations.
The facility failed to update care plans for two residents, leading to discrepancies in their documented needs and actual care. One resident's care plan inaccurately listed them as a smoker, while another's care plan had incorrect dialysis days and lacked bleeding precautions despite anticoagulant use. Observations showed missing bed cane rails, contrary to the care plan. Interviews confirmed these discrepancies, indicating a failure to revise care plans to reflect current conditions.
The facility failed to ensure that five nurse aides completed a training program within four months of employment, as required. The facility's policy did not address this requirement, and the aides were not enrolled in a CNA class. The ADON acknowledged the lack of CNA classes due to the absence of a teacher, with plans for aides to start classes at a nearby facility. The DON and ADON confirmed the expectation for certification within four months.
The facility failed to maintain accurate narcotic count records, with missing signatures and documentation in narcotic count records from January to February 2025. Staff admitted to signing out before shift end, contrary to policy. Administration confirmed expectations for proper documentation, but acknowledged lapses in conducting required counts.
The facility exceeded the acceptable medication error rate, reaching 10.34%, due to an LPN failing to prime insulin pens as per manufacturer's instructions for three residents. The LPN admitted to not being shown how to prime the pens, and the facility lacked a policy on insulin administration. The administration acknowledged the expectation for a lower error rate and proper insulin pen use.
The facility failed to properly label and store medications, affecting a resident directly and potentially impacting all residents. Insulin pens and Aplisol vials were not discarded after expiration, and the medication refrigerator's temperature was often out of range. Staff interviews revealed a lack of clarity in monitoring and managing medication storage.
The facility failed to ensure required members attended QAPI meetings, as evidenced by sign-in sheets showing missing members like the Medical Director and Infection Preventionist. The Administrator acknowledged the expectation for all required members to be present.
The facility failed to maintain proper infection control practices by using a single-user blood glucose monitor on multiple residents without adequate disinfection. An LPN was observed using the monitor on six residents, wiping it with a bleach wipe but not ensuring it remained wet for the required time. The facility's infection control policy was not followed, with inadequate surveillance and documentation of infections. The DON and Administrator acknowledged the lack of review and update of the Infection Prevention and Control Program.
The facility failed to maintain an effective IPCP, particularly in antibiotic stewardship, affecting all residents. In December 2024, six residents were started on antibiotics without cultures or proper documentation. In January 2025, 17 residents were started on antibiotics, with similar documentation issues. The facility's leadership acknowledged the lack of program review and infection tracking.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by multiple observations of environmental deficiencies. A strong urine smell was detected near the front nurses' station, indicating a lack of cleanliness and sanitation. Additionally, several rooms and hallways were observed with damaged door casings, missing or stained ceiling tiles, and exposed ductwork, which compromised the facility's homelike atmosphere and potentially posed safety hazards to residents. Interviews with the Maintenance Supervisor and the Administrator revealed that while the Maintenance Supervisor conducts regular walkthroughs and addresses issues as they arise, there is no formal log for immediate repairs, and there are currently no extra ceiling tiles available for replacement. The Administrator acknowledged the expectation for ceiling tiles to be free from stains, holes, and cracks, and for door casings to be in good repair. However, the facility's failure to maintain these standards was evident in the observations made during the survey.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding transfers or discharges to a hospital, as required by their Discharge/Transfer Policy. This deficiency was identified for six residents out of a sample of 12, with a facility census of 48. The policy mandates that a signed transfer or discharge notice be given to the resident and/or representative, and in emergencies, to ambulance personnel. However, the facility did not adhere to this policy, as there was no documentation of written notifications for the transfers of these residents. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the facility's practice was to notify families by phone rather than in writing, which is contrary to the policy. The Administrator acknowledged the expectation for written notifications to be provided. The lack of written documentation was confirmed through record reviews, which showed multiple instances of hospital transfers without corresponding written notifications for the involved residents or their representatives.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the bed hold policy at the time of transfer to the hospital. This deficiency was identified for six residents out of a sample of twelve, with a facility census of 48. The facility's policy requires that residents or their representatives be notified in writing about the bed hold policy when a resident is transferred to a hospital. However, the records for these residents showed no documentation that such written notifications were provided at the time of transfer. Instead, staff members signed the bed hold policies on behalf of residents who were unable to sign, without ensuring that the residents or their representatives received the necessary written information. Interviews with the Assistant Director of Nursing (ADON) and other staff revealed that the practice was to send a copy of the bed hold policy along with the transfer sheet to the hospital, and to notify families by phone rather than in writing. The ADON admitted to signing the bed hold policies when residents were unable to do so, a practice that had been ongoing since her tenure at the facility. The facility's leadership, including the Administrator, Director of Nursing (DON), and ADON, acknowledged the expectation that bed hold policies should be given to residents or their representatives, but the documentation and communication practices did not align with this expectation.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of two residents. Resident #38, who was admitted with diagnoses of chronic pain, anxiety disorder, and major depressive disorder, had a care plan indicating they were a smoker. However, interviews with the resident and the Director of Nursing revealed that the resident no longer smoked, indicating that the care plan was not updated to reflect this change. Smoking assessments were supposed to be conducted quarterly with each Minimum Data Set (MDS) assessment, but the care plan was not revised accordingly. Resident #202, admitted with multiple diagnoses including heart failure, absence of right leg below the knee, pneumonia, chronic kidney disease stage 5, and end-stage renal disease, had discrepancies in their care plan. The care plan indicated the use of bed cane rails for positioning and transfers, but observations over several days showed no bed cane rails were present. Additionally, the care plan inaccurately listed dialysis days and did not include bleeding precautions despite the resident receiving an anticoagulant. Interviews with the resident and facility staff confirmed these discrepancies, highlighting the failure to update the care plan to reflect the resident's current condition and needs.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that five nurse aides completed a nurse aide training program within four months of their employment, as required by regulations. The facility's policy on Nurse Aide Training, dated 05/01/23, did not address the requirement for certification within four months. This oversight had the potential to affect all residents, given the facility's census of 48. Specific instances included Nurse Aides H, I, J, K, and L, who were not enrolled in a Certified Nursing Assistant (CNA) class despite being employed for more than four months. During interviews, the Assistant Director of Nursing (ADON) acknowledged that the facility does not currently offer CNA classes due to the absence of a teacher. It was noted that all nurse aides were expected to start CNA classes at a nearby skilled nursing facility in the first week of March. The Administrator, Director of Nursing (DON), and ADON confirmed their expectation for nurse aides to be certified within four months of hire, highlighting a gap between policy and practice.
Failure to Maintain Accurate Narcotic Count Records
Penalty
Summary
The facility failed to establish a comprehensive system for the accurate reconciliation of controlled medications, as evidenced by the lack of signatures and documentation in the narcotic count records. The facility's policy required that a physical inventory of narcotics be completed at each shift change by two licensed nurses or Certified Medication Technicians (CMTs), with both oncoming and offgoing staff signing to verify the count. However, the review of narcotic count records from January 1, 2025, through February 28, 2025, revealed numerous instances where signatures and initials were missing from both oncoming and offgoing CMTs across multiple shifts. Additionally, the total number of narcotic drug cards was not documented on the card count verification form for many shifts. Interviews with CMTs indicated that some staff members signed out for the end of shift count before their shift was over, acknowledging that this practice was inappropriate. The facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), confirmed that they expected both oncoming and offgoing staff to sign the card count verification form and that signing ahead of time was not acceptable. Despite these expectations, the Administrator admitted that the nurses had not been conducting the required card counts, indicating a systemic failure in adhering to the facility's narcotic count policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an error rate of 10.34%. This was observed during the administration of insulin to three residents, where the Licensed Practical Nurse (LPN) did not follow the manufacturer's instructions for priming insulin pens. Specifically, the LPN did not prime the insulin aspart, Fiasp, and Lantus pens with two units of insulin before administering the prescribed doses to the residents. This oversight was noted during observations of the LPN administering insulin to Residents #1, #9, and #31. During interviews, the LPN admitted to never being shown how to prime an insulin pen, indicating a lack of proper training or oversight. The facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), acknowledged the expectation for a medication error rate below five percent and for insulin pens to be primed according to the manufacturer's instructions. However, the facility did not provide a policy regarding the administration of insulin, which may have contributed to the errors observed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, affecting one resident directly and potentially impacting all residents. Observations revealed that insulin pens and Aplisol vials were not discarded after their expiration dates, contrary to the facility's policy and manufacturer recommendations. Specifically, insulin pens for three residents were found with opened dates exceeding the 28-day usage limit, and an Aplisol vial was observed with an opened date beyond the 30-day limit. Additionally, the facility's medication storage practices were inadequate, as evidenced by improper temperature maintenance in the medication refrigerator. The temperature logs showed multiple instances where the refrigerator's temperature fell outside the recommended range, with some entries indicating temperatures as low as 22 degrees Fahrenheit. Despite these discrepancies, there was no evidence that staff reported these out-of-range temperatures to the administration, nor were corrective actions documented. Interviews with staff, including LPNs and the Director of Nursing, revealed a lack of clarity and consistency in monitoring and managing medication storage. The staff admitted to a team effort approach in discarding expired medications, but there was no clear accountability. Furthermore, the temperature logs were incomplete, and staff were unsure of the correct temperature range for medication storage, indicating a systemic issue in adhering to medication management protocols.
QAPI Meetings Lacked Required Member Attendance
Penalty
Summary
The facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members, as evidenced by the review of meeting sign-in sheets and interviews. The facility's policy mandates that the QAPI Committee include specific members such as the Administrator, Director of Nursing, Medical Director, and others, but does not address the requirement of the Infection Preventionist as a committee member. During the QAPI meeting on April 25, 2024, the sign-in sheet showed attendance by the Administrator, Director of Nursing, Infection Preventionist, and at least two other staff members, but there was no record of the Medical Director attending. In the subsequent QAPI meeting on July 17, 2024, the sign-in sheet indicated the presence of the Administrator, a Nurse Practitioner, and at least two other staff members, but lacked attendance by the Director of Nursing and the Infection Preventionist. The Administrator acknowledged during an interview that she would expect all required members to be present at the QAPI meetings. This inconsistency in attendance of required members at the QAPI meetings led to the deficiency noted in the report.
Inadequate Infection Control Practices in Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain proper infection control practices, specifically in the use of a blood glucose monitor that could be disinfected and shared between residents. Observations revealed that a Licensed Practical Nurse (LPN) used a CareSens N blood glucose monitor, which is intended for single-user/home use only, on multiple residents without proper disinfection. The LPN was observed using the monitor on six residents, wiping it with a Microdot bleach wipe, but failing to ensure the glucometer remained wet for the required three minutes to achieve complete disinfection. The facility's Infection Control Policy, dated April 10, 2019, outlined the standards for the Infection Prevention and Control Program (IPCP), which included coordination, oversight, surveillance, and data analysis. However, the facility did not adhere to these standards, as evidenced by the lack of proper surveillance and documentation of infections. The facility's Monthly Infection Logs for December 2024 and January 2025 showed numerous residents started on antibiotics without proper documentation of signs, symptoms, or cultures performed. The Director of Nursing (DON), who also served as the Infection Preventionist, acknowledged the lack of a root cause analysis for infections and the absence of infection tracking. Interviews with the Administrator and the DON revealed that the facility had not reviewed or updated the IPCP in over a year. The Administrator admitted that the IPCP should include current standards, policies, and procedures, as well as an infection surveillance program. The DON indicated that the charge nurse was responsible for observing signs and symptoms of infection and consulting with the nurse practitioner or physician. However, there was a lack of follow-through in ensuring labs and cultures were ordered when indicated, and updates on infection resolution were not documented on the tracking tool.
Deficient Antibiotic Stewardship and Infection Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program (IPCP) with a focus on antibiotic stewardship, which had the potential to affect all residents. The facility's policies outlined the need for coordination, oversight, surveillance, and data analysis, but these were not effectively implemented. The Antibiotic Stewardship Policy required microbiology to guide therapy, documentation of indications, and appropriate antibiotic use, but these were not consistently followed. In December 2024, six residents were started on antibiotics, but no cultures were performed, and documentation was lacking for signs, symptoms, and resolution of infections. The Infection Tracking Log showed that two residents did not have prescribed antibiotics documented, and four residents lacked documentation of signs or symptoms. Additionally, there was no documentation of organisms for wounds or UTIs, and four residents did not have documentation showing if the appropriate antibiotic was ordered. In January 2025, 17 residents were started on antibiotics, with only two cultures performed. The Infection Tracking Log revealed that none of the residents had documentation of infection resolution, and there was a lack of documentation for organisms and appropriate antibiotic orders. The facility's Administrator and Director of Nursing acknowledged the deficiencies, noting that the IPCP had not been reviewed or updated, and that infections were not being tracked or analyzed for root causes.
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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 De Soto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Desoto | 4.4 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center Inc | 6.5 mi | ★★★★★ | 10 | 0 |
| Superior Manor Of Festus, Llc | 8.3 mi | ★★★★★ | 0 | 0 |
| Crystal Oaks | 9.4 mi | ★★★★★ | 4 | 0 |
| Fountainbleau Nursing Center | 9.7 mi | ★★★★★ | 12 | 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.