Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Provide Scheduled Showers: A resident with moderate cognitive impairment and total dependence for bathing did not receive scheduled showers as documented. The shower log showed only one bath/shower during the review period, and the family reported the resident was dirty with dried feces on the bed and had only received one bath since admission. Staff interviews confirmed the resident was supposed to receive showers on a set schedule and that bathing should be documented in the shower sheet and EHR.
An LVN entered a resident’s room and assisted him during vomiting without first putting on a gown and mask, despite the resident being on contact precautions for C-Diff and the facility requiring EBP for direct care. The resident had severe cognitive impairment, a feeding tube, and diagnoses including chronic respiratory failure with hypoxia and obstructive uropathy/reflux uropathy. A family video showed the LVN in the room without PPE while holding a bin near the resident’s face as he continued to vomit.
Detached Air Conditioner Exposed Outside: A resident room AC unit was observed detached from the wall and exposed to the outside, leaving 1 of 3 unoccupied resident room units reviewed not properly secured. The Mnt Dir stated there was no maintenance request for the unit, it may have been kicked or pushed out of its frame, and the ADM stated staff were expected to report maintenance concerns immediately and that AC units should be sealed properly.
A resident with severe cognitive impairment and multiple medical conditions experienced a change of condition for which a physician ordered a urinalysis. Review of the electronic record showed no urinalysis results for the period reviewed, despite the order and concurrent initiation of antibiotics. The ADON and DON both confirmed they could not locate the lab results in the EHR and acknowledged that staff should have obtained the specimen or documented any inability to do so. The ADM stated her expectation that clinical staff follow physician orders and document unsuccessful attempts, noting that failure to obtain ordered labs can prevent the physician from addressing potential health issues.
A resident with dementia, coronary artery disease, rheumatoid arthritis, and multiple stage 3 and stage 4 pressure ulcers required substantial/maximal assistance and turning/repositioning at least every two hours per her care plan. Review of the EHR for April showed missing documentation of the turn/reposition task on several second and third shifts, despite staff interviews (CNA, LVN, DON, and ADM) confirming that residents must be checked/changed and turned/repositioned every two hours and that aides are required to chart this care at least once per shift. Staff stated that if it is not charted, it is considered not done, and that lack of documentation could lead to skin breakdowns, while the resident reported that staff do check, change, and reposition her.
A resident with dementia and moderate cognitive impairment eloped through an exit alarmed door in the early morning hours and was outside unsupervised for about 20 to 30 minutes. Staff found her on the sidewalk, but she refused to get into a vehicle with a CNA she did not know and continued walking until staff stopped her near a small bridge by an active creek. The event was unwitnessed, and interviews showed staff searched the area after the alarm sounded and later assessed the resident with no injuries.
Failure to Document Morphine Administration on MAR and Narcotic Record A resident with cancer and severe pain received multiple PRN morphine doses from several nurses, but several administrations were not documented on the MAR and some were not documented on the narcotic record at the time of administration. Staff stated they knew they were supposed to document the doses, and the corporate nurse confirmed the MAR and narcotic record documentation requirements.
Food safety deficiencies were identified in the kitchen when temperature logs for multiple refrigerators and a walk-in refrigerator were missing morning entries, a reach-in freezer lacked a secondary thermometer, and two ice scoops were stored bowl-side up on a tray atop the ice machine with wet areas beneath them. The DM acknowledged that separate thermometers were needed for each unit and that ice scoops should be protected from dust and standing water.
Infection Control Lapses During Incontinence and Wound Care: Two residents were observed receiving care without proper hand hygiene. A CNA provided incontinence care to a resident with dementia and total incontinence while keeping soiled gloves on to clean, apply barrier cream, and place a new brief. An LVN performed sacral wound care for a resident with severe cognitive impairment and pressure-ulcer risk, changing gloves multiple times but not performing hand hygiene between steps. Both staff members acknowledged they had been trained on hand hygiene and glove changes.
Failure to develop a pain care plan for a resident with PRN opioid analgesic use. A resident with moderately impaired cognition and diagnoses including heart failure, kidney failure, and non-Alzheimer's dementia had no documented pain care plan, even though he received Tylenol with Codeine PRN and reported ongoing right hip pain after a prior fall. The DON stated she did not know why the pain care plan was missing and noted care plans were based on assessments and the comprehensive assessment.
A CNA failed to ensure privacy for a resident during incontinent care by not closing the room door or privacy curtain, resulting in the resident's body being exposed to the hallway. The resident, who was alert and oriented, expressed discomfort about being seen. Facility leadership and policy confirmed the expectation for privacy during personal care.
A CNA did not change soiled gloves or perform hand hygiene during incontinent care for a resident with multiple medical conditions, despite facility policy and prior training requiring these infection control measures. The CNA continued care and assisted with repositioning and dressing the resident while wearing soiled gloves, only removing them and using hand sanitizer after leaving the room.
Medication Cart #1 was found unlocked and unattended in an open office in the memory care unit, with staff unaware of how long it had been unsecured or how to lock it. The Charge Nurse admitted to forgetting to lock the cart after adding new medications, in violation of facility policy requiring all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
The facility failed to secure Medication Cart #1, leaving it unlocked and unattended in an open office within the memory care unit. Charge Nurse A admitted responsibility for the oversight, which posed a risk of unauthorized access by residents. Interviews with the DON and Administrator confirmed that staff were trained to keep carts locked, aligning with the facility's policy requiring carts to be locked when not in sight.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure Resident #7 received the necessary assistance with activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. Resident #7’s MDS assessment dated 05/14/2026 identified him as a [AGE]-year-old male with a BIMS score of 09, indicating moderate cognitive impairment, and diagnoses including metabolic encephalopathy, atelectasis, and idiopathic gout. The care plan dated 05/07/2026 identified an ADL performance deficit and stated he was totally dependent on staff for bed bath/shower as necessary. Record review of the shower sheet log for May showed Resident #7 received only one shower/bed bath on 05/15/2026 during the period reviewed from 05/07/2026 through 05/20/2026. The family member stated Resident #7 had only received one shower/bath since admission and reported that on 05/13/2026 he was dirty with dried feces on the bed, with photos available. The family also stated his shower days were supposed to be Monday, Wednesday, and Friday. During interviews, the DOR stated the DON was told by the family that Resident #7 was dirty and that staff were gotten to shower him. CNA F stated Resident #7’s shower days were Monday, Wednesday, and Friday and that showers or bed baths were to be documented on shower sheets and in the electronic health record. LVN A stated if a resident was not provided a shower, they would become dirty and had the right to be clean, and that if it was not documented, it did not happen. The Administrator stated her expectation was that residents receive scheduled showers on their assigned days and that the risk of not receiving a shower included skin breakdown and dignity issues.
Failure to Use PPE During Care for Resident With C-Diff
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for Resident #9 when LVN A entered the resident’s room and assisted him during an episode of vomiting without first putting on a gown and mask. Resident #9 was a male resident with chronic respiratory failure with hypoxia and obstructive uropathy and reflux uropathy. His admission MDS noted a BIMS score of 3, indicating severely impaired cognition, and he had a feeding tube. His care plan dated 04/29/2026 indicated contact precautions were to be used when providing resident care, and the facility’s EBP sign stated that all providers and staff must wear gloves and a gown for high-contact activities. During review of a video provided by the resident’s family member, LVN A was observed walking into the room without gloves or a gown and assisting the resident while he vomited, including holding a rubber bin near his face as vomiting continued. The resident’s family member stated staff had not followed infection control procedures and reported the resident had been diagnosed with C-Diff and placed on isolation. The ADON stated the resident had C-Diff, was on contact isolation, and staff were required to wear PPE and follow EBP when providing direct care. LVN A stated she should have put on a gown before entering the room because the resident had C-Diff and EBP was required, but said she forgot because she believed it was more important to ensure the resident did not choke on his vomit.
Detached Air Conditioner Exposed Outside
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when 1 of 3 unoccupied resident room air conditioning units reviewed was found detached from the wall and exposed to the outside. During observation, the unoccupied resident room air conditioner was not properly attached to the wall, allowing exposure to the outside. During interview, the Maintenance Director stated he was responsible for fixing broken items within his expertise and that maintenance issues were reported through Maintenance Care, which he checked every hour. He stated there was no maintenance request for the air conditioning unit, and after observing it, he said it appeared someone may have kicked or pushed it out of the wooden frame. He stated the unit would be fixed that day and noted the risk could include leaks or an access point to pests. The ADM stated it was her expectation that staff observe and report maintenance concerns immediately, and that all air conditioner units should be sealed properly and free of any air space or outside view. The facility policy stated it was the policy to maintain a safe, functional, controlled, and comfortable environment and to keep furnishings and equipment safe and in good repair.
Failure to Obtain Ordered Urinalysis and Document Results
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain laboratory services as ordered and to have results available for review for one resident. A male resident with severe cognitive impairment, a history of acute respiratory failure with hypoxia, dysarthria following stroke, and Alzheimer's disease had a physician order for a urinalysis (UA) on 02/25/2026 following a change of condition. Record review from 02/25/2026 through 04/30/2026 showed no UA results in the electronic clinical record. The resident’s medical record also reflected standing orders for periodic blood work, including CBC, CMP, lipid panel, valproic acid level every six months, and Hgb and A1C every three months, but the cited deficiency focused on the missing UA ordered on 02/25/2026. During interviews, the ADON reported she was unable to locate the UA results for the resident and stated that the UA "had to be done" because the physician had ordered antibiotics. She also stated that if staff had been unsuccessful in obtaining a urine sample, this should have been documented. The DON confirmed she could not find the UA results in the EHR and stated that, because the physician ordered the UA, staff should have obtained the lab. The DON noted that staff were aware of the change of condition, contacted the physician, and that antibiotics were ordered and administered while the resident’s vital signs remained within normal limits. The ADM stated her expectation that clinical staff follow physician orders and document if a sample cannot be obtained, and she acknowledged that failure to obtain ordered labs could lead to potential health issues that the physician would not be able to address.
Failure to Accurately Document Turn/Reposition Care for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain accurate medical records for a resident requiring frequent turning and repositioning. Record review of the resident’s MDS assessment showed she was an older female with moderate cognitive impairment (BIMS score of 10) and diagnoses including coronary artery disease, dementia, and rheumatoid arthritis. She required substantial/maximal staff assistance for repositioning and had two stage 3 pressure ulcers and one stage 4 pressure ulcer on admission. Her care plan, dated 04/06/2026, directed staff to follow facility protocols for prevention of skin breakdown and specified that she needed assistance to turn and reposition at least every two hours. Review of the electronic health record (EHR) task documentation for April 2026 showed missing entries for the turn/reposition task on multiple shifts: the third shifts on 04/17/2026, 04/19/2026, and 04/20/2026, and the second and third shifts on 04/28/2026. CNAs, an LVN, the DON, and the Administrator all stated that residents were to be checked/changed and turned/repositioned every two hours and that staff were required to chart completion of these tasks in the EHR at least once per shift. They further stated that if documentation was not present in the EHR, it meant the task was not completed or the staff member forgot to document it, and that lack of documentation could lead to skin breakdowns. The resident herself reported that staff do check, change, and reposition her, but the requested facility policy on charting incontinence care and turning/repositioning was not provided to surveyors prior to exit.
Resident Eloped and Reached Area Near Creek Without Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with dementia and moderate cognitive impairment when the resident eloped from the facility through the 200-hall exit door at approximately 4:30 a.m. The resident had diagnoses including unspecified dementia without behavioral disturbance, generalized anxiety disorder, and major depressive disorder. Her MDS reflected a BIMS score of 09, and the record showed she used a walker and could ambulate with minimal assistance. Although the care plan later reflected risk for wandering and elopement, the resident was not in the secure unit at the time of the incident and was able to leave the building unattended. When the exit alarm sounded, staff identified that the resident was missing after checking rooms on the 200 hall. One nurse looked outside the exit and did not see her, and another nurse went outside to search the perimeter. A CNA searched by car and found the resident on the sidewalk about 25 feet south of the driveway. The resident refused to get into the vehicle because she did not know the man, and she continued walking until she reached a small bridge near an active creek, about 500 feet from the facility entrance, where staff were able to stop her and bring her back. Staff interviews showed that the elopement was unwitnessed and that the resident was outside the facility unsupervised for approximately 20 to 30 minutes. The resident later stated she thought she was late for work and had left the door on her own. The ADM stated that if the resident had fallen into the creek or gone off the sidewalk, she could have been exposed to multiple hazards, injuries, or worse. The incident was reported to state authority, police, the Medical Director, and the resident's family member.
Failure to Document Morphine Administration on MAR and Narcotic Record
Penalty
Summary
The facility failed to maintain an accurate system of records for controlled drugs for one resident receiving morphine for pain related to lung cancer with metastasis. Resident #39 was cognitively intact, had cancer, and was on pain medication therapy. Her order was for Morphine Sulfate 15 mg by mouth every 4 hours as needed for pain, and her February 2026 MAR reflected only one documented dose on 02/06/26. The narcotic count record showed multiple doses of morphine were administered to Resident #39 by several nurses, including LVN D, LVN E, RN F, LVN G, LVN C, and LVN H, on multiple dates in February 2026. However, several of those doses were not documented on the MAR, and some were not documented on the narcotic record at the time of administration. LVN C stated she documented one dose on the narcotic record and 24-hour report but not on the MAR, and LVN H stated she did not document a dose on either the narcotic record or the MAR. LVN D, LVN G, and RN F also stated they administered morphine but did not document it on the MAR, and LVN E did not return the surveyor’s call. During interviews and observation, Resident #39 was noted to be in significant pain, crying out, grimacing, and stating she was having a lot of pain. On one occasion, LVN C stated she gave morphine, signed it out on the narcotic count record, and the record reflected the dose, but the MAR did not. The corporate nurse stated staff were supposed to document the morphine dose on both the narcotic record and the MAR. The facility policy stated the MAR is initialed by the person administering the medication, or electronically stamped if using an electronic record.
Food Safety and Ice Scoop Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its only kitchen. During observation, temperature logs for two reach-in refrigerators and the walk-in refrigerator were missing morning entries for 2/3, 2/6, 2/7, 2/8, and 2/9. The reach-in freezer closest to the steam tables also did not have a secondary thermometer inside it. In interview, the DM stated that each refrigerated unit should have a separate thermometer and that it was important to verify the built-in thermometer was accurate. The facility also failed to store ice scoops in a manner that protected them from contamination. During observation, two ice scoops were stored bowl-side up on a tray on top of the only ice machine, and the tray had wet areas directly beneath the scoops. The DM stated that the facility had previously used a self-drying container, but the lid had broken off and the container had come loose from the wall several months earlier. She stated that ice scoops should be protected from dust and not stored in standing water because it could contaminate the ice.
Infection Control Lapses During Incontinence and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control. During incontinence care for a female resident with non-Alzheimer's dementia, seizure disorder, and total incontinence of urine and bowel movements, a CNA cleaned the resident's buttocks, did not change gloves or perform hand hygiene, applied barrier cream with soiled gloves, and then placed a new brief without changing gloves or performing hand hygiene. The CNA later stated she was nervous and acknowledged she had been trained to change gloves and perform hand hygiene during incontinence care. During wound care for a male resident with severely impaired cognitive skills, seizure disorder, and risk for pressure ulcers, an LVN removed the sacral dressing, changed gloves multiple times, but did not perform hand hygiene after glove changes while cleansing the wound, patting it dry, applying treatment, and applying the dressing. The LVN stated she forgot to perform hand hygiene during wound care and said she had been trained to perform hand hygiene after changing gloves. The corporate nurse stated staff were supposed to perform hand hygiene and change gloves during incontinence care and when changing gloves, and the facility policy reflected hand hygiene after removing gloves and soap and water when hands are visibly soiled and before and after assisting a resident with toileting.
Failure to Develop a Pain Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #29 that included measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. The deficiency specifically involved pain management, as the resident did not have a care plan for pain despite having an order for Tylenol with Codeine #3 every 6 hours as needed for pain and receiving doses on 02/03/26 and 02/07/26. Resident #29's admission MDS, dated 02/02/26, identified him as a [AGE] year-old male with a BIMs score of 13 and moderately impaired cognition. His diagnoses included heart failure, kidney failure, and non-Alzheimer's dementia, and the assessment did not reflect pain. Review of the comprehensive care plan showed it was not dated and did not include a pain care plan. During interview and observation on 02/10/26, the resident stated he had pain in his right hip, needed pain medication, had told a CNA about the pain, and reported he had fallen at another facility and had suffered with hip pain since then. The DON stated on 02/11/26 that she did not know why the resident did not have a pain care plan and that care plans were developed based on assessments and the comprehensive assessment.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide privacy to a male resident during incontinent care. The CNA entered the resident's room, did not close the door to the hallway, and did not properly close the privacy curtain. While removing the resident's covers and gown, the resident's body was exposed to the hallway. The surveyor observed this and partially closed the door before entering the room, at which point the CNA acknowledged she was performing care and then fully shut the door. The resident, who was alert, oriented, and able to make decisions, later stated he did not want others to see his body and acknowledged he would be visible if the door and curtain were not closed. Interviews with the CNA, Director of Nursing (DON), and Administrator confirmed that the facility's expectation is for staff to ensure privacy by closing doors and curtains during personal care. The CNA admitted that by not closing the door and curtain, the resident's privacy and dignity were compromised. The facility's policy on resident rights also specifies the right to personal privacy and confidentiality, including during personal care and accommodations.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection prevention and control procedures during incontinent care for a male resident with multiple diagnoses, including PTSD, hypertension, diabetes mellitus, and renal insufficiency. The resident was alert, oriented, and required assistance for incontinence care. During the observed care, CNA A donned clean gloves and performed perineal and rectal cleaning but did not change soiled gloves or perform hand hygiene between tasks, despite handling soiled materials and repositioning the resident multiple times. The CNA continued to use the same soiled gloves to assist another staff member in repositioning the resident, pulled up a clean brief, and fastened it, all without changing gloves or washing hands until after leaving the resident's room. The facility's policies on perineal care and infection control require hand hygiene before and after care, as well as glove changes when gloves become soiled. CNA A acknowledged awareness of these procedures but did not follow them during the observed incident, attributing the lapse to being nervous and distracted. The Director of Nursing confirmed the expectation for hand hygiene and glove changes as outlined in facility policy. Review of training records indicated that CNA A had previously attended in-service training on hand hygiene and incontinent care.
Medication Cart Left Unlocked and Unattended in Memory Care Unit
Penalty
Summary
A deficiency occurred when Medication Cart #1 was found unlocked and unattended in an open, unlocked office within the memory care unit. At the time of observation, all residents were in their rooms, and two CNAs were present in the hallway. One CNA stated she was unaware that the medication cart was unlocked, did not know how long it had been left that way, and did not know how to lock it. The Charge Nurse later acknowledged that she had accessed the cart earlier to add new medications and must have forgotten to lock it afterward. The facility's policy requires that medication carts be locked and secured when not in use, and that only authorized personnel have access to medications. The failure to secure the medication cart was confirmed through interviews with staff, including the CNAs, the Charge Nurse, the Administrator, and the DON. All acknowledged that the unlocked cart could have allowed residents access to medications. The facility's written policy also specifies that medications must be stored in locked compartments and that the cart should remain locked when unattended, which was not followed in this instance.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an incident involving Medication Cart #1. During an observation and interview, the medication cart was found unlocked and unattended in an open, unlocked office within the memory care unit. This area was accessible to two residents and housekeeping staff who were observed walking nearby. Charge Nurse A, who was responsible for the cart, admitted to leaving it unlocked and acknowledged the risk of residents accessing the medications. Further interviews revealed that the Director of Nursing (DON B) confirmed all staff were trained to keep medication carts locked when unattended, emphasizing the risk of unauthorized access to medications. Administrator C also stated that the medication cart should not have been left unlocked and unattended, particularly in a memory care unit where residents could potentially access harmful medications. The facility's policy on medication administration clearly stated that medication carts must be locked when out of sight of the administering nurse, which was not adhered to in this instance.
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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 Desoto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Methodist Transitional Care Center-desoto Llc | 0.9 mi | ★★★★★ | 5 | 0 |
| Five Points Nursing And Rehabilitation | 1.4 mi | ★★★★★ | 6 | 0 |
| Park Village Healthcare And Rehabilitation | 2.2 mi | ★★★★★ | 9 | 2 |
| Windsor Gardens | 2.7 mi | ★★★★★ | 14 | 0 |
| Williamsburg Village Healthcare Campus | 2.7 mi | ★★★★★ | 36 | 5 |
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