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 Stonebridge Desoto during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A facility failed to include necessary BiPAP settings in a physician's order for a resident with COPD, sleep apnea, and other conditions. The resident reported using BiPAP at night and needing assistance, but the LPN was unaware of the settings. The DON and Administrator acknowledged the expectation for settings to be listed in the order.
The facility failed to maintain sanitary conditions in its food service areas, with observations of dirt, debris, and grime in the kitchen and serving areas. The deep fryer contained dark brown grease, and dented cans were found. Cleaning schedules and temperature logs were incomplete, and the dish machine did not consistently meet required temperatures. A dietary aide was observed without a hair restraint, and interviews revealed a lack of oversight.
Facility staff failed to adhere to infection control practices, including Enhanced Barrier Precautions and hand hygiene, during care for multiple residents. Staff did not wear required protective equipment, neglected hand hygiene between glove changes, and improperly handled wound care supplies, leading to potential contamination.
The facility did not provide access to survey results, affecting all 46 residents. The policy required survey results to be in a binder in a common area, but observations showed no binder was present. Interviews with residents revealed they were unaware of the survey results' availability. The Administrator expected the results to be accessible without residents needing to ask.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Facility Fails to Include BiPAP Settings in Physician's Order
Penalty
Summary
The facility failed to ensure that a physician's order for bilevel positive airway pressure (BiPAP) included the necessary settings for a resident. This deficiency was identified during a review of the facility's policy and the resident's medical records. The facility's policy on CPAP/BiPAP support, dated March 2015, requires a review of the physician's order to determine the oxygen concentration, flow, and PEEP pressure for the machine. However, the Physician's Order Sheet for the resident, dated 03/13/25, did not include an order for BiPAP settings, despite having an order for a trilogy device with oxygen at bedtime. The resident, who has a medical history of chronic obstructive pulmonary disease, obstructive sleep apnea, type 2 diabetes, diastolic heart failure, and atrial fibrillation, reported using BiPAP at night and needing assistance with the mask and machine. During an observation, the resident was seen turning on the machine and starting BiPAP. Interviews with staff, including an LPN and the Director of Nursing, revealed that the LPN was unaware of the BiPAP settings, and both the DON and the Administrator acknowledged that they would expect the settings to be listed in the order.
Facility Fails to Maintain Sanitary Conditions in Food Service Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service areas, as observed during multiple inspections. On March 10, 2025, the kitchen was found with dirt and debris under the main food prep table, grime on the dishwasher, sticky floors, and dirty ceiling tiles. Additionally, the deep fryer contained dark brown grease with leftover food residue, and there were dented cans of crushed pineapple and chunk light tuna. On March 13, 2025, similar unsanitary conditions were noted, including the absence of a thermometer in the walk-in refrigerator or freezer, and frying pans with black buildup. Further observations on March 13, 2025, revealed unsanitary conditions in the upstairs kitchen serving area, with food crumbs, dirt, and debris on the floor, and food debris on the warming station and plate storage rack. The cleaning schedule showed gaps, with no documentation of cleaning on March 12 and 13, 2025. Temperature logs for the upstairs kitchen refrigerator and freezer were incomplete, with no records for February and March 2025. Food temperature logs were also lacking, with records only starting on March 11, 2025. The facility's high-temperature dish machine was not consistently operating at the required temperatures, with several instances of recorded wash and rinse temperatures below the necessary levels. Additionally, a dietary aide was observed preparing food without a hair restraint. Interviews with the Dietary Manager and Administrator highlighted a lack of awareness and oversight regarding the kitchen's condition and equipment, contributing to the unsanitary environment.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to maintain appropriate infection control practices, particularly in the application of Enhanced Barrier Precautions (EBP) and hand hygiene during resident care. For Resident #20, staff did not don gloves and gowns as required by EBP when performing mechanical lift transfers and incontinent care. During these procedures, staff touched the resident's bed with their clothes and failed to perform hand hygiene before donning gloves. Additionally, a CNA placed a roll of trash bags on the resident's bed and then returned it to their pocket, further compromising infection control. In the case of Resident #22, the Registered Nurse (RN) did not perform hand hygiene before donning gloves and failed to use a barrier when placing supplies on the resident's bedside table. The RN also did not establish a clean field for dressing supplies and handled dressing materials without proper hand hygiene between glove changes. These actions led to potential contamination of the wound care process. For Resident #23, the RN did not apply skin prep and drape to the peri-wound area as required, and the wound vac tubing fell on the floor during the procedure. The RN attempted to clean the tubing with wound cleaning solution instead of replacing it, despite the availability of additional supplies. Throughout the wound care process, the RN repeatedly failed to perform hand hygiene between glove changes, further compromising the sterility of the procedure.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to provide access to survey results, which had the potential to affect all 46 residents. The facility's policy, dated April 2007, required that a copy of the most recent standard survey and state-approved plans of correction be maintained in a three-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. However, observations conducted from March 10 to March 13, 2025, revealed that no survey binder was found at the nurses' station or activities room. Interviews with three residents indicated that they were unaware of the availability of survey results or where to find them. The Administrator acknowledged that she would expect the survey results to be available for residents to read without having to ask.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 44 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Hillcrest Care Center Inc | 4.2 mi | ★★★★★ | 10 | 0 |
| Baisch Nursing Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Superior Manor Of Festus, Llc | 10.7 mi | ★★★★★ | 0 | 0 |
| Crystal Oaks | 11.8 mi | ★★★★★ | 4 | 0 |
| Fountainbleau Nursing Center | 11.9 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.