Above 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 Nhc Healthcare, Desloge during CMS and state inspections, most recent first.
A deficiency was identified in the pain management of a resident with hypertensive heart disease, heart failure, COPD, diabetes mellitus, dementia, and a Stage 3 pressure ulcer. The resident, prescribed hydrocodone-acetaminophen, experienced multiple instances where pain assessments were not conducted as per physician orders. Despite vocalizing pain and exhibiting signs of distress, staff did not consistently provide pain medication or non-pharmacological interventions. Miscommunication among staff further contributed to the resident's pain not being addressed over several days, highlighting gaps in assessment, communication, and intervention strategies.
The facility failed to maintain a resident's dignity and privacy by leaving them exposed during incontinent care. The resident, with severe cognitive impairment and other conditions, was left visible to someone outside due to open blinds. Interviews confirmed that staff should have closed the door, blinds, and privacy curtains.
The facility failed to notify residents and/or their responsible parties in a timely manner when their account balances were within $200.00 of the SSI limit or exceeded the SSI limit. This affected two residents who received Medicaid benefits, and no notifications were provided as required by the facility's policy. Interviews revealed that the facility was aware of the issue but failed to take appropriate action.
Facility staff failed to safely administer medications to a resident with kidney failure, leaving them unsupervised with medication for over an hour without proper documentation or assessment for self-administration competency.
The facility failed to ensure proper placement and maintenance of Foley catheter tubing and drainage bags for two residents, resulting in uncovered drainage bags and tubing touching the floor. Staff interviews confirmed that these practices did not align with the facility's policies for catheter care and infection control.
The facility failed to ensure proper care of enteral feeding for two residents. An LPN added extra water to the Jevity formula for one resident, exceeding the ordered amount, while an RN used a plunger to push the formula through the feeding tube for another resident, contrary to the physician's orders. The facility lacked a tube feeding policy, indicating insufficient guidelines and training for staff.
The facility failed to follow a physician's order for oxygen for one resident and failed to obtain a physician's order for oxygen for another resident. One resident received less oxygen than prescribed, while another received oxygen without any documented order.
The facility failed to document ongoing assessments, monitoring, and communication between the facility and the dialysis center for two residents requiring dialysis services. There were multiple missed opportunities for documenting daily weights and consistent communication with the dialysis center.
The facility failed to identify, assess, and provide supportive interventions for two residents diagnosed with PTSD. Both residents lacked PTSD assessments and care plans addressing their triggers, despite being prescribed medications for their conditions. The Social Service Director and MDS Coordinator acknowledged the oversight.
The facility failed to ensure that two residents diagnosed with dementia had personalized care plans addressing their specific needs. Interviews with staff confirmed that dementia should be addressed in care plans with personalized interventions, but the care plans for these residents lacked such details.
The facility failed to maintain proper infection control practices during incontinent care, Foley catheter care, and wound care for multiple residents. Staff did not perform hand hygiene between glove changes, used improper cleaning techniques, and allowed catheter drainage bags to touch the floor. Additionally, wound care procedures were compromised by the use of unclean equipment and failure to perform hand hygiene.
Inadequate Pain Management for Resident with Complex Medical Conditions
Penalty
Summary
The deficiency identified in the report pertains to the inadequate pain management provided to Resident #26 in a long-term care facility. Resident #26 had multiple complex medical conditions, including hypertensive heart disease, heart failure, COPD, diabetes mellitus, dementia, and a Stage 3 pressure ulcer. The resident was prescribed hydrocodone-acetaminophen for pain management, and pain assessments were to be conducted regularly as per physician orders. However, observations revealed instances where the resident was in pain and not adequately attended to. On multiple occasions, staff members failed to assess the resident's pain, offer pain medication, or provide non-pharmacological interventions despite the resident expressing pain and discomfort. Throughout the documented period, there were several instances where Resident #26 vocalized pain, requested assistance, and exhibited signs of distress during wound care procedures. Despite these clear indicators, staff members did not consistently address the resident's pain needs promptly or effectively. The resident's pain was evident through verbal cues, moaning, and requests for help, yet appropriate pain management interventions were not consistently implemented. This lack of timely and comprehensive pain management for Resident #26 highlights a significant gap in the facility's adherence to professional standards of practice and the resident's individual care plan. The report also highlighted instances where Resident #26's pain was not adequately addressed due to miscommunication among staff members. The resident reported being in severe pain and not receiving pain medication as prescribed. It was noted that there was a lack of awareness among staff regarding the resident's pain status over several days, indicating a breakdown in communication and coordination of care. This deficiency in pain management for Resident #26 underscores the importance of consistent and thorough assessment, communication, and intervention strategies to ensure residents receive appropriate and timely pain relief in long-term care settings.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure staff treated residents with dignity and respect by leaving a resident exposed during care. Resident #45, who has severe cognitive impairment, Parkinson's disease, Alzheimer's disease, and dementia, was observed lying in bed while two CNAs performed incontinent care. The CNAs did not close the blinds to the window, which allowed a person mowing the yard to see into the room. Additionally, one CNA left the room to obtain more wipes, leaving the resident's genitalia area exposed. Interviews with the CNAs and the Assistant Director of Nursing confirmed that the door, window blinds, and privacy curtains should have been closed to maintain the resident's privacy. The facility's policy on dignity, dated August 2009, mandates that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, including maintaining bodily privacy during personal care and treatment procedures.
Failure to Notify Residents of Account Balances
Penalty
Summary
The facility failed to notify residents and/or their responsible parties in a timely manner when their account balances were within $200.00 of the Social Security (SSI) limit or when the balances exceeded the SSI limit. This deficiency affected two residents who received Medicaid benefits. Specifically, Resident #2 had account balances that exceeded the SSI limit in February 2024, and Resident #8 had account balances that exceeded the SSI limit in February 2024. No notifications were provided to the residents or their representatives regarding these balances, as required by the facility's policy. Interviews with the Business Office Manager (BOM), the Administrator, and the Regional Accountant revealed that the facility was aware of the issue but failed to take appropriate action. The BOM admitted to not sending the required notification letters to the residents or their representatives. The Administrator expected the accounts to be managed properly and notifications to be sent when necessary. The Regional Accountant confirmed that notice letters should have been sent but were not, and only quarterly statements were provided. The issue was exacerbated by the sudden departure of the previous office manager in December 2023.
Medication Administration Deficiency
Penalty
Summary
Facility staff failed to administer medications in a safe and effective manner for one resident out of six sampled residents. The resident, who had a diagnosis of kidney failure and required dialysis, had an order for sevelamer carbonate to be taken with meals. However, there was no documentation of an order for the resident to self-administer the medication, nor were there assessments for the resident's competency to do so. The care plan did not address self-administration of the medication. Observations showed that the resident was left unsupervised with a cup of five pills for over an hour before self-administering the medication when food arrived. Interviews with staff revealed that the Certified Medication Technician and the Administrator were aware of the practice but did not ensure proper documentation or assessment. The Assistant Director of Nursing confirmed that there should have been an order and/or care plan for the resident to self-administer medication at the dining room table.
Improper Foley Catheter Care and Placement
Penalty
Summary
The facility failed to ensure proper placement and maintenance of Foley catheter tubing and drainage bags for two residents. Resident #10, who has diagnoses including unspecified dementia, anxiety disorder, and retention of urine, was observed multiple times with an uncovered catheter drainage bag and tubing that touched the floor. These observations occurred while the resident was both in bed and in a wheelchair, indicating a consistent failure to maintain proper catheter care and infection control practices as outlined in the facility's policy. Additionally, the resident's care plan specified that the catheter drainage bag should be kept in a privacy cover, which was not adhered to during the observations. Similarly, Resident #307, who has diagnoses including unspecified dementia with agitation, depression, and neuromuscular dysfunction of the bladder, was observed with catheter tubing on the floor while seated in a wheelchair. During a transfer from the wheelchair to the bed, the catheter drainage bag fell to the floor and was placed back on the bed without proper handling. Interviews with staff, including CNAs and RNs, confirmed that catheter tubing and drainage bags should not touch the floor and should be kept covered for privacy and dignity, which was not followed in these instances.
Improper Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure proper care of enteral feeding for two residents, leading to deficiencies in the administration of tube feedings. For Resident #46, the Licensed Practical Nurse (LPN) added extra water to the Jevity 1.5 CAL formula, administering a total of 255 ml of water, which was 55 ml over the ordered 200 ml. The LPN stated that the extra water was added to thin out the product to aid in administration. This action was not in accordance with the physician's orders and demonstrated a lack of adherence to proper tube feeding protocols. For Resident #308, the Registered Nurse (RN) used a plunger to push the Jevity 1.5 CAL formula through the feeding tube, rather than allowing it to flow by gravity as ordered. The RN admitted that using the plunger was incorrect and acknowledged that all physician's orders should be followed. The Assistant Director of Nursing (ADON) confirmed that nurses should not use a plunger during tube feedings and emphasized the expectation for staff to follow orders as written. The facility did not provide a tube feeding policy, further highlighting the lack of proper guidelines and training for staff in administering enteral feedings.
Failure to Follow and Obtain Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow a physician's order for oxygen for one resident and failed to obtain a physician's order for oxygen for another resident. Resident #33, who has diagnoses including COPD and dependence on supplemental oxygen, had an order for oxygen at four liters per minute via nasal cannula. However, observations showed the resident receiving oxygen at three liters per minute, and the tubing was undated. The resident expressed difficulty breathing without the oxygen, indicating the importance of adhering to the prescribed oxygen level. Resident #307, diagnosed with unspecified dementia, atherosclerotic heart disease, peripheral vascular disease, and dysphagia, was observed receiving oxygen at two to three liters per minute via nasal cannula on multiple occasions. However, there was no documentation of a physician's order for oxygen use or for changing the oxygen tubing or humidifier. The resident's care plan and admission MDS did not address oxygen therapy, and the Assistant Director of Nursing confirmed that there should be orders for oxygen and that these orders should be followed.
Failure to Document Dialysis Care and Communication
Penalty
Summary
The facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis center for two residents who required dialysis services. For Resident #23, the facility did not consistently document daily weights as ordered, with multiple missed opportunities in January, February, and March 2024. Additionally, there was a lack of consistent pre and post dialysis communication with the dialysis center. The resident's care plan did not address renal dialysis and the necessary assessments and monitoring. The resident had diagnoses including end stage renal disease (ESRD), diabetes mellitus (DM), and a left lower below the knee amputation. For Resident #27, similar deficiencies were noted. The facility failed to document daily weights consistently, with numerous missed opportunities in January, February, and March 2024. There was also a lack of consistent communication between the facility and the dialysis center, with the dialysis center not completing their portion of the communication form. The resident had diagnoses including ESRD, dyspnea, DM, and bilateral below the knee amputations. Interviews with facility staff revealed that the dialysis center refused to fill out the paperwork and send it back, and daily weights were not consistently completed and documented as ordered.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident #27 was admitted with diagnoses of PTSD, insomnia, and depression but had no documentation of a PTSD assessment. The resident's care plan did not address PTSD or any triggers that could cause behaviors. Similarly, Resident #44, who was admitted with diagnoses of PTSD and depression, also lacked documentation of a PTSD assessment, and their care plan did not include any information about past trauma or triggers for behaviors. Both residents were prescribed medications for their conditions, but the necessary PTSD screenings and care plans were not completed as per the facility's policy. During interviews, the Social Service Director admitted that the PTSD screenings were not completed for these residents. The Minimum Data Set (MDS) Coordinator confirmed that residents with PTSD diagnoses should have care plans addressing their triggers with individualized interventions. The facility's failure to follow its own policy on trauma-informed care resulted in inadequate support for these residents, as evidenced by the lack of PTSD assessments and appropriate care plans.
Failure to Provide Personalized Dementia Care Plans
Penalty
Summary
The facility failed to ensure that two residents diagnosed with dementia had personalized care plans to address their specific needs. Resident #10, who was admitted with age-related dementia and cognitive loss, had a care plan that did not address dementia, specific problems, interventions, or goals for dementia care. Similarly, Resident #50, who was admitted with dementia, severe cognitive impairment, mood disturbance, anxiety, cognitive communication deficit, and Down's Syndrome, also had a care plan that did not address dementia or include specific problems, interventions, or goals for dementia care. Both residents' care plans were last reviewed in March 2024 and were found lacking in these critical areas during the survey review. Interviews with facility staff, including the MDS Coordinator and the Assistant Director of Nursing (ADON), confirmed that dementia should be addressed in a resident's care plan with personalized interventions. The MDS Coordinator specifically mentioned that the care plan should include medications, activities of daily living, care, wandering, and behaviors. The ADON also stated that she would expect the care plan to be person-centered and reflect the resident's current diagnoses. The facility's failure to include these elements in the care plans of Residents #10 and #50 constitutes a deficiency in providing appropriate treatment and services for residents diagnosed with dementia.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control practices during incontinent care for three residents, Foley catheter care for two residents, and wound care for one resident. During incontinent care, staff did not perform hand hygiene between glove changes and used improper techniques for cleaning the peri area. For example, one CNA did not sanitize hands between glove changes and cleaned the peri area from back to front, which is against the facility's policy. Another CNA touched various items in the resident's room without performing hand hygiene after providing care, further compromising infection control protocols. In the case of Foley catheter care, staff failed to keep the catheter drainage bag below the level of the bladder and allowed it to touch the floor. One CNA did not perform hand hygiene or change gloves after the catheter drainage bag fell to the floor and continued to provide care. Another CNA reconnected the catheter tubing without cleaning the tip, which could lead to contamination. These actions were contrary to the facility's policy on urinary catheter care, which emphasizes the importance of hand hygiene and maintaining a closed system to prevent infections. During wound care for one resident, the RN did not perform hand hygiene between glove changes and used personal scissors without cleaning them. The RN's gait belt touched the open wound, and the same gloves were used to apply different wound care products. Additionally, the RN dropped a package of kling wrap on the floor, picked it up, and continued to use it without changing gloves. These actions violated the facility's policy on performing dressing changes, which requires hand hygiene between glove changes and the use of clean equipment to prevent wound contamination.
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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 Desloge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Meadows | 1.5 mi | ★★★★★ | 1 | 0 |
| St Joe Manor | 4 mi | ★★★★★ | 0 | 0 |
| Community Manor | 6.9 mi | ★★★★★ | 1 | 0 |
| Camelot Nursing And Rehabilitation Center | 7.2 mi | ★★★★★ | 7 | 0 |
| Southbrook Nursing Center | 7.3 mi | ★★★★★ | 4 | 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.