Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Healthcare Center during CMS and state inspections, most recent first.
A facility failed to follow care plans for PEG site care for two residents and nail care for two dependent residents. Observations and staff interviews showed PEG drainage sponges were not in place as directed and that two residents had long, jagged fingernails despite care plan interventions for cleaning, filing, and clipping. The DON and an MDS nurse confirmed the care plans were not being followed.
Failure to Provide Required Nail Care: Two residents had long, jagged, and unclean fingernails despite facility policy and orders for regular nail care. An LPN, CNA, and DON confirmed the findings, including one resident with a contracted hand and another with brown substance and odor on the hand. Records showed both residents required assistance with ADLs/personal hygiene, and one had severe cognitive impairment.
Two residents with PEG tubes did not receive ordered site care. One resident was observed without a drainage sponge at the PEG site, and another resident’s PEG insertion site had a brown dried substance present with no drainage sponge in place. Staff confirmed the missing sponge and unclean site, and the DON stated PEG sites are to be cleaned daily and kept covered with a drainage sponge per orders.
A resident's debit card was misappropriated by an agency CNA, who used it for unauthorized purchases totaling $242.82. The resident, who was cognitively intact, had been using the card with staff assistance for vending machine purchases. The facility's Administrator and DON were notified of the missing card, and an investigation revealed the CNA's involvement. The facility's policy on preventing exploitation was not effectively implemented, leading to this incident.
A dietary staff member failed to perform hand hygiene after picking up a pen from the floor during food temperature checks, risking cross-contamination. The staff member admitted the oversight, and the administrator acknowledged the error, highlighting a lapse in following the facility's infection control policy.
The facility failed to accurately submit staffing data into the PBJ system for two quarters, triggering alerts for excessively low weekend staffing despite having adequate staff. The Administrator and Payroll Coordinator were aware of the issue but could not identify the cause, and system glitches were reported.
A facility failed to obtain a physician's order for a bolster sheet used as a restraint for a resident to prevent falls. Despite the facility's policy requiring such orders, the bolster sheet was implemented without one following a fall. Staff confirmed the use of the bolster sheet to prevent the resident from getting out of bed, but the DON was unaware of the need for an order. The resident, admitted with osteomyelitis of the vertebra, had experienced several falls.
A resident with Parkinson's Disease expressed concerns about inconsistent oral hygiene care, noting her teeth had not been brushed regularly. Observations confirmed poor oral hygiene, and staff interviews revealed that oral care, part of daily personal hygiene, was not consistently performed. The DON acknowledged the failure to implement the resident's ADL care plan, which included oral hygiene.
A resident with Parkinson's Disease, requiring assistance with oral hygiene, did not receive daily oral care at the facility. Despite being cognitively intact, the resident reported infrequent assistance from CNAs, leading to poor oral hygiene. Observations confirmed a yellow substance on the resident's teeth, and interviews with staff acknowledged the oversight and potential health risks.
A resident with Alzheimer's disease was found with a Levothyroxine pill in her bed, indicating a failure in medication administration. Despite facility policy requiring nurses to ensure medication consumption, the resident's known tendency not to swallow pills was not adequately managed. The medication was documented as given, highlighting a lapse in adherence to safety protocols.
The facility failed to complete Quarterly MDS assessments within the required timeframe for two residents. The delay was due to corrections made by the MDS nurse, resulting in assessments being finalized a month late. The residents had diagnoses of Alzheimer's disease and alcohol dependence with alcohol-induced persisting dementia.
Failure to Follow PEG Site and Nail Care Plans
Penalty
Summary
The facility failed to implement care plans for PEG site care for two residents and nail care for two dependent residents. The facility policy titled Comprehensive Plan of Care stated that each resident must have a comprehensive person-centered care plan with measurable objectives and timeframes to meet medical, nursing, and psychosocial needs. The report identified that the care plans for Resident #2 and Resident #9 included PEG site care with instructions to clean the PEG site with daily wound care and apply a new drainage sponge at bedtime, while the care plans for Resident #7 and Resident #48 included nail care interventions to have fingernails and toenails cleaned, filed, and clipped as needed. For Resident #2, observation during medication administration showed no drainage sponge present around the PEG tube site, and the LPN confirmed the sponge was not present. Resident #2 had diagnoses including dysphagia following cerebral infarction and cognitive communication deficit, and the quarterly MDS indicated the resident was rarely or never understood. For Resident #9, observation and interview showed the PEG site did not have a drainage sponge in place, and the LPN confirmed PEG sites are to be cleaned each shift and that the care plan was not followed. Resident #9 was admitted with a diagnosis including encounter for attention to gastrostomy, and the MDS showed a BIMS score of 14. For Resident #7, observation showed the resident sitting in a Geri-chair with the left hand contracted and the fingernails on that hand excessively long, jagged, and about 3/8 inch long. The LPN confirmed the long fingernails and stated the nail care care plan was not followed. Resident #7 had diagnoses including Alzheimer's disease and a BIMS score of 4. For Resident #48, observations showed long, jagged fingernails on both hands with brown substance underneath, and the resident stated the fingernails needed cutting and had not been clipped in a while. The MDS nurse confirmed that personal hygiene including fingernail care was included in the interventions and agreed the care plans were not followed.
Failure to Provide Required Nail Care
Penalty
Summary
The facility failed to provide nail care for 2 of 19 sampled residents who required assistance with ADLs. Facility policy stated that all residents were to receive nail care on a regularly scheduled basis, including routine cleaning, inspection, trimming, and filing as needed. For Resident #7, an observation showed the resident sitting in a Geri-chair with a contracted left hand and fingernails on that hand that were excessively long and jagged, measuring about 3/8 inch. An LPN confirmed the long fingernails and acknowledged the resident was at risk for skin issues due to the contracture and long nails. The resident’s MAR showed an order for fingernails and toenails to be cleaned, filed, and clipped as needed every Friday, and the CNA Kardex noted the nails needed to be kept short to reduce the risk of scratching or injury from picking at skin. For Resident #48, observations showed long, jagged fingernails on both hands, about one-half inch long, with brown substance underneath, and a thick, crusty brownish yellow substance covering the palm of the right hand with a mild odor. The resident stated his fingernails needed cutting and had not been clipped in a while. A CNA confirmed the long, dirty fingernails, the substance in the palm, and the odor, and stated staff should wash his hands at least daily and clip and file his fingernails every week and as needed. The DON also confirmed the long, dirty fingernails, the odor, and the substance on the hand, and stated staff should look at fingernails every day and wash hands more than once a day. Resident #48’s record showed diagnoses including congestive heart failure and need for assistance with personal care, and his MDS indicated substantial to maximal assistance with personal hygiene and severe cognitive deficits.
Failure to Provide Ordered PEG Tube Site Care
Penalty
Summary
The facility failed to provide PEG tube care in accordance with physician orders and professional standards of practice for two residents with PEG tubes. A typed statement on company letterhead dated 9/17/25 and signed by the DON stated the facility did not have a specific policy related to PEG tube care and that staff were to follow physician orders concerning PEG tubes. For Resident #2, observation during medication administration on 9/16/25 showed no drainage sponge present around the PEG tube site, and LPN #3 confirmed the sponge was not present. The resident’s order listing dated 03/26/2025 directed staff to clean the PEG site with daily wound care and apply a new drainage sponge at bedtime. Resident #2 had diagnoses including gastrostomy status and dysphagia following cerebral infarction, and the MDS indicated the resident was rarely/never understood. For Resident #9, observation and interview on 9/17/25 showed the PEG insertion site had a brown dried substance present and no drainage sponge in place. LPN #1 confirmed the site condition and stated floor nurses were responsible for PEG care. LPN #2 also confirmed the site was not clean and had no drainage sponge in place, stating PEG sites are to be cleaned each shift and that the drainage sponge protects the skin around the tubing; she reported she last cleaned the site on Thursday, 9/11/25, and it appeared not to have been cleaned since then. The DON stated PEG sites are to be cleaned daily and documented in the EMAR, and that the insertion site is always to be kept clean with a drainage sponge applied to prevent infection and reduce skin irritation and breakdown. Resident #9’s order summary directed staff to clean the PEG site with daily wound care and apply a new drainage sponge at bedtime; the resident had a diagnosis of encounter for attention to gastrostomy and was cognitively intact per the MDS.
Misappropriation of Resident's Debit Card by Agency CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving a resident's debit card. The incident involved an agency Certified Nursing Assistant (CNA) who was assigned to the resident during her shift. The resident, who was cognitively intact, reported that his debit card was lost after he had been using it to purchase items from a vending machine with staff assistance. The card was later found to have been used for unauthorized purchases totaling $242.82. The facility's Administrator and Director of Nursing were notified of the missing debit card by a Registered Nurse on the night shift. Despite efforts to locate the card, it was not found, and the resident initially declined to cancel the card due to the inconvenience. The following day, with the assistance of a Social Worker, the resident contacted his bank and discovered the unauthorized transactions. An investigation revealed that the purchases were made by the agency CNA, who had worked only one shift at the facility and used the resident's debit card details to make the purchases. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the CNA's actions. The CNA had been oriented on her duties and responsibilities, including the prohibition of exploitation, but still managed to misuse the resident's debit card. The facility's failure to prevent this incident highlights a lapse in safeguarding residents' personal property and ensuring that staff adhere to established protocols.
Failure to Prevent Cross-Contamination in Kitchen
Penalty
Summary
The facility failed to prevent the possibility of cross-contamination to food during a kitchen observation. During the lunch meal steam table temperature checks, a dietary staff member dropped a pen on the floor and then retrieved it without performing hand hygiene before continuing to check and record food temperatures. This action was observed and noted as a failure to adhere to the facility's infection prevention and control policy, which is designed to prevent the transmission of communicable diseases and infections. The dietary staff member admitted during an interview that she was nervous and acknowledged that she should have washed her hands to prevent the spread of bacteria. The facility administrator also confirmed that the staff member should have either washed her hands or used a new pen to avoid potential cross-contamination of the food.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for the first and second quarters of 2024. The facility's policy requires timely and accurate submission of staffing data through the CMS PBJ system. However, the PBJ Staffing Data Reports for both quarters revealed excessively low weekend staffing, which triggered a compliance alert. Despite having more than adequate staffing, with a staff ratio usually above 3.0, the facility was unable to determine the cause of the low staffing trigger. Interviews with the Administrator and Payroll Coordinator revealed that the facility was aware of the issue but could not identify the problem. The Payroll Coordinator confirmed that the data was submitted correctly and had contacted CMS for assistance but had not received a response. The Coordinator also mentioned difficulties in printing the PBJ Staffing Data Report due to system glitches. The facility's staffing grid indicated sufficient staffing levels, suggesting that the issue might be related to data submission or system errors rather than actual staffing shortages.
Lack of Physician's Order for Restraint Use
Penalty
Summary
The facility failed to ensure that there was a physician's order for a bolster sheet used as a restraint to prevent a resident from getting out of bed. This deficiency was identified for one of the 27 residents sampled, specifically Resident #81. The facility's policy on restraints, revised on 11/28/17, requires that orders for restraints specify the rationale for use and the type of restraint. However, upon review, it was found that there was no physician's order for the concave mattress or bolster sheet used for Resident #81, despite these being implemented as measures to prevent falls. Observations and interviews with staff, including a Registered Nurse and the Director of Nurses, confirmed that the bolster sheet was used to prevent the resident from getting out of bed, and it was implemented following a fall on 6/8/24. The Director of Nurses was unaware that an order was needed for the bolster sheet, which was used to define the bed's parameters. Resident #81, who was admitted on 7/12/23 with a diagnosis of osteomyelitis of the vertebra, had experienced several falls, prompting the use of the concave mattress and bolster sheet as preventive measures.
Failure to Implement ADL Care Plan for Resident's Oral Hygiene
Penalty
Summary
The facility failed to implement an Activities of Daily Living (ADL) care plan for a resident, identified as Resident #93, who had been at the facility for about three months. The resident expressed concerns about her oral hygiene, stating that while the Certified Nursing Assistants (CNAs) provided good baths, they had not consistently brushed her teeth. She noted that her teeth had not been brushed since one day last week, and she had to request assistance for it to be done. Observations confirmed poor oral hygiene, with a yellow substance present between her teeth and gum line. Interviews with staff, including a Licensed Practical Nurse (LPN) and a CNA, confirmed that oral care was part of daily personal hygiene and should be performed daily. However, it was revealed that the resident's oral care had not been completed as required. The Director of Nursing (DON) acknowledged that the CNAs were responsible for oral care and that the resident's ADL care plan, which included oral hygiene, was not implemented properly. The resident's admission record indicated a diagnosis of Parkinson's Disease without Dyskinesia and a need for assistance with personal care.
Failure to Provide Daily Oral Care
Penalty
Summary
The facility failed to provide daily oral care for a resident who was unable to perform this activity independently. The resident, who was admitted to the facility three months prior and had a diagnosis of Parkinson's Disease, required partial to moderate assistance with oral hygiene. Despite being cognitively intact, the resident reported that the Certified Nursing Assistants (CNAs) only helped her brush her teeth a few times since her admission. She expressed that if she did not ask for assistance, her oral care was neglected. The resident attempted to clean her teeth using a wet washcloth and paper towels, but this was ineffective. Observations confirmed the resident's poor oral hygiene, with a yellow substance noted between her teeth and gum line. Interviews with the Licensed Practical Nurse (LPN) and CNA confirmed that oral care was not provided as required. The LPN acknowledged the resident's poor oral condition and the potential health issues that could arise from neglecting oral care. The Director of Nursing (DON) confirmed that CNAs were responsible for daily personal hygiene, including oral care, and acknowledged that the resident had been overlooked in this aspect of care.
Medication Administration Failure
Penalty
Summary
The facility failed to prevent the possibility of an accident by not ensuring that a physician-ordered medication was properly administered and consumed by a resident. During an observation, a resident's representative found a blue pill, identified as Levothyroxine 150 mcg, in the resident's bed. This medication was supposed to have been administered earlier that morning. Interviews with the nursing staff, including LPNs and the Director of Nurses, confirmed that the facility's policy requires nurses to stay with residents to ensure they swallow their medications. However, it was revealed that the resident, who has Alzheimer's disease, has a known tendency not to swallow all her medications, which was not adequately addressed by the staff. The resident's Medication Administration Record indicated that the medication was documented as given daily, despite the pill being found in the bed. The LPN responsible for administering the medication on the night in question admitted to giving the medication while the resident was in her wheelchair but did not ensure it was swallowed. Another LPN, who had previously administered medication to the same resident, confirmed the importance of staying with the resident to ensure medication consumption, especially given the resident's known behavior. The failure to adhere to the facility's medication administration policy resulted in the potential for medication errors and safety hazards.
Failure to Timely Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) resident assessments within the required fourteen-day time frame for two residents. According to the facility's policy and federal regulations, a comprehensive and standardized assessment of each resident's functional capacity must be conducted periodically. However, the MDS 3.0 NH Final Validation Report indicated that the assessments for these residents were completed late, with the assessment completion date being more than 14 days after the assessment reference date. The MDS nurse confirmed that the delay was due to corrections made to both assessments, which caused them to be completed late. The assessments should have been closed by the specified deadline, but were not finalized until a month later. The Director of Nursing expressed that the expectation was for the MDS assessments to be completed within the designated time frame set by CMS. The residents involved had medical diagnoses of Alzheimer's disease and alcohol dependence with alcohol-induced persisting dementia, respectively.
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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 Southaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Southaven | 1.4 mi | ★★★★★ | 12 | 1 |
| Landmark Of Desoto | 3 mi | ★★★★★ | 10 | 0 |
| Graceland Rehabilitation And Nursing Care Center | 5.2 mi | ★★★★★ | 0 | 0 |
| Delta Blues Health & Rehabilitation | 7.1 mi | ★★★★★ | 7 | 1 |
| Parkway Health And Rehabilitation Center | 7.2 mi | ★★★★★ | 1 | 0 |
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