Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Methodist Transitional Care Center-desoto Llc during CMS and state inspections, most recent first.
The facility did not ensure that G-tube dressings were changed and dated as ordered for multiple residents, and failed to keep formula tubing capped during downtime, leaving tube ends exposed and uncapped. These lapses were observed through direct inspection, family reports, and staff interviews, with documentation inconsistencies and lack of staff awareness contributing to the deficiencies.
A resident with multiple medical conditions alleged that a medication aide attempted to force medication after she refused it. The DON filed a grievance and suspended the aide, but after an internal investigation and consultation with corporate, the incident was not reported to the State Agency within the required two-hour timeframe, as staff believed it was not reportable. This failure to report the allegation as required resulted in a deficiency.
A resident with a PICC line for IV antibiotics did not have her dressing changed as ordered, with the dressing remaining in place beyond the required interval. Nursing staff cited workload and communication lapses as reasons for missing the scheduled dressing change, and the infection control preventionist and DON were unaware of the overdue dressing until it was identified during the survey.
A resident was denied access to a private telephone after a family member requested the removal of all communication devices, despite the resident being able to make decisions and having no diagnosis of dementia. Facility staff, including the DON and Administrator, complied with the family member's request and instructed staff not to provide a phone, even though facility policy and the resident's records supported the resident's right to communication.
Medication Cart #1 was found unlocked and unattended in a hallway, with no staff present nearby. A medication tech, responsible for two carts, admitted to forgetting to lock the cart when switching between them. Both the DON and Administrator confirmed the incident, and the facility's policy on locked medication carts was not provided when requested.
The facility did not ensure that calls to centralized staff areas were consistently answered and failed to maintain functioning portable phones at nurses' stations, resulting in missed communications for 17 residents. Staff interviews and surveyor observations confirmed that after-hours calls often went unanswered, and portable phones were either missing or not properly charged, impeding residents' and representatives' ability to reach staff regarding care concerns.
The facility did not ensure privacy for resident council meetings, holding them in an open activities room where staff and providers repeatedly entered and interrupted the sessions. Leadership confirmed that private meeting spaces were unavailable due to other uses, and residents reported frequent disruptions during their meetings.
A resident with stage IV pressure ulcers had a negative pressure wound device set above the physician-ordered setting on two consecutive days. Nursing staff were unclear about the correct settings, and the device was only adjusted after the discrepancy was identified. Facility policy required verification of orders and correct device settings, which was not followed.
Surveyors found that kitchen staff failed to properly label, date, and seal food and drinks in the refrigerator and dry storage, and did not separate dented cans from other food items. Staff interviews confirmed these responsibilities were not met, potentially exposing residents to expired or contaminated food.
A resident with significant medical needs did not receive timely assistance with grooming and incontinence care due to staff failing to respond promptly to call lights. Interviews and records indicated that staff sometimes turned off call lights without providing care, leading to delays in meeting the resident's needs and causing dissatisfaction.
A medication aide failed to sanitize a blood pressure cuff and perform hand hygiene before contact with two residents, both with significant medical histories, while administering medications and checking vital signs. This occurred despite facility policies and in-service training requiring hand hygiene and disinfection of shared equipment between resident contacts. The DON and Administrator confirmed these expectations during interviews.
A resident with dementia and impaired cognition was discharged home alone without appropriate supervision, care arrangements, or necessary services in place. The discharge was carried out despite documented concerns about the resident's ability to care for herself, an unsafe home environment, and lack of involvement from responsible parties or medical providers. The facility did not complete required assessments or ensure post-discharge support, resulting in the resident being left in an unsafe situation.
Four residents with complex medical needs did not have person-centered care plans that included measurable objectives or discharge planning, despite their varied conditions and imminent plans to return home. Staff interviews confirmed that care plans were not updated to address discharge goals, and the facility could not provide a care plan policy when requested.
A resident with dementia and cognitive deficits experienced a significant decline in mental status, including increased confusion and need for assistance with ADLs. Despite these changes, staff did not complete a Significant Change in Status Assessment as required, and the resident's care plan was not updated to reflect her altered condition. Staff interviews confirmed the assessment should have been completed when the resident's cognitive status declined.
A resident with a history of multiple health issues experienced severe pain after an unwitnessed fall in a LTC facility. Despite orders for pain medication, there was a delay in administration, and the resident's pain was not adequately assessed or managed. The resident was later diagnosed with a hip fracture requiring surgery. Communication lapses and a lack of timely intervention by staff contributed to the deficiency.
A resident with a history of falls experienced a deficiency in care after a fall, as the facility failed to conduct routine neuro checks and adequately manage pain. Despite physician orders for pain medication and monitoring, the resident's pain assessments were not documented, and medication administration was delayed. The resident's condition worsened, leading to a hospital diagnosis of a hip fracture requiring surgery. Interviews revealed lapses in communication and documentation among staff.
A resident with a history of falls did not have the administration of Tylenol documented on the Medication Administration Record after a fall. LVN A failed to conduct and document pain assessments and neuro checks, despite the resident expressing pain. The incident report was delayed, and the facility's documentation policies were not followed, leading to a deficiency.
A resident with a history of falls experienced an unwitnessed fall and subsequent pain, but the family was not notified immediately. The resident was later diagnosed with a hip fracture requiring surgery. The facility's staff, including the LVN responsible, failed to inform the family, contrary to the facility's policy.
A resident with a history of falls and cognitive impairment was repeatedly found without access to their call light, despite facility policy and staff acknowledgment of its importance in preventing falls. Observations showed the call light was often placed out of reach, and staff interviews confirmed the expectation for it to be accessible at all times.
The facility failed to properly store, date, and label food items in the kitchen's walk-in freezer, exposing them to potential contaminants. Open cases of frozen cookies and hamburger patties, along with an uncovered coil of sausage, were found without proper labeling or packaging. The Dietary Manager confirmed these actions were against the facility's policy, which requires all food to be sealed, labeled, and dated.
A CNA failed to perform hand hygiene while serving meals to four residents, despite being trained on infection control procedures. The residents had various medical conditions, including atrial fibrillation, dementia, and diabetes, and required assistance with daily activities. The DON confirmed the importance of hand hygiene to prevent infection spread.
Failure to Provide Proper G-Tube Care and Maintain Closed Feeding Systems
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications related to enteral feeding for four residents with gastrostomy tubes. Specifically, the facility did not ensure that gastrostomy tube (G-tube) dressings were changed and dated as ordered for three residents. In one case, a resident's family reported finding the G-tube dressing soiled with a foul odor and the feeding tube end uncapped and dirty over multiple days. Documentation in the Medication Administration Record (MAR) indicated that dressing changes were marked as completed, but observations and family-provided photos contradicted this, showing undated and soiled dressings. Interviews with nursing staff revealed uncertainty about when dressings were last changed and acknowledged that not dating dressings could lead to confusion about care provided. Additionally, the facility failed to ensure that formula tubing was sealed with a cap during downtime for two residents. Observations showed that the feeding tube ends were left uncapped and hanging from IV poles when not in use, creating an open system. Staff interviews confirmed that the expectation was to use the clear plastic cap provided with the formula bags to close the line when not connected to the resident, but this was not consistently done. Some staff were unaware of the importance of capping the tubing or did not consider it within their responsibilities. The facility's policies required daily dressing changes, proper documentation, and infection control practices to prevent contamination and infection. However, interviews with the infection control preventionist, DON, and administrator revealed a lack of awareness and oversight regarding missed dressing changes and undated dressings. The failure to follow established protocols for G-tube care and formula tubing management was observed and confirmed through interviews, record reviews, and photographic evidence.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than two hours if the alleged violation involved abuse or resulted in serious bodily injury. Specifically, an allegation of abuse made by a resident was not reported to the State Agency within the required timeframe. The resident, a female with diagnoses including gastrostomy malfunction, COPD, type 2 diabetes, unspecified dementia, and cellulitis of the abdominal wall, reported to the DON that a medication aide had pinched her mouth and attempted to force medication after she refused it due to its taste. The resident's family was present at the time of the allegation. Upon receiving the allegation, the DON filed a grievance, suspended the medication aide pending investigation, and completed life satisfaction surveys for abuse and neglect. The DON reported the incident to the facility's abuse coordinator (the Administrator) and the corporate office. However, after an internal investigation and consultation with the corporate office, it was determined that the incident was not reportable to the State Agency, as there was a witness present and the family later suggested the resident may have been confused due to dementia. As a result, the incident was not reported to the State Agency as required by regulation. Interviews with facility staff confirmed awareness of the two-hour reporting requirement for abuse allegations. The Administrator acknowledged that the incident was not reported to the State Agency based on corporate guidance and the internal investigation's findings. Facility records showed that in-service training on abuse and neglect was conducted after the incident, but the initial failure to report the allegation within the mandated timeframe constituted a deficiency.
Failure to Timely Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for a resident with a PICC line. The resident, a female admitted with an active infection related to hardware in her right lower leg, was receiving IV antibiotics through a PICC line. Physician orders specified that the PICC line dressing should be changed every seven days and as needed, and the facility's policy also required weekly dressing changes or sooner if the dressing was not intact. During observation, it was noted that the resident's PICC line dressing was dated 14 days prior and was coming off on one side, although the immediate area around the insertion site was clean and intact. Interviews with nursing staff revealed that the dressing change had been missed; one LVN admitted she noticed the overdue dressing but delayed changing it until after administering antibiotics, while another LVN responsible for the dressing change stated she forgot due to being busy with admissions and discharges and failed to communicate this to the oncoming nurse. The infection control preventionist and DON both confirmed that the dressing change had not been completed as ordered and were unaware of the overdue status until the survey. Record review and staff interviews confirmed that the facility's policy and physician orders were not followed, resulting in the PICC line dressing remaining unchanged for longer than the prescribed interval. The staff acknowledged that the failure to change the dressing as ordered could increase the risk of infection, and the breakdown in communication and time management contributed to the deficiency.
Failure to Provide Resident Access to Private Communication
Penalty
Summary
The facility failed to ensure a resident had access to a private form of communication, specifically by removing the landline telephone from the resident's room and refusing to provide a telephone upon request. This action was taken at the insistence of a family member who did not want the resident to communicate with other family members. Interviews with staff, including the DON and Administrator, confirmed that the facility complied with the family member's request despite having the ability to provide private communication. Staff also reported being instructed not to provide a phone to the resident, and documentation in the resident's records indicated the phone was removed per family request. The resident in question was admitted following a serious vehicle collision and was in the process of recovery. Although family members claimed the resident had dementia and 'Sun Downers,' the resident's personal physician stated there was no diagnosis of dementia and that any mental deficiency would likely be temporary and related to the accident. The resident was able to communicate clearly, recall events accurately, and was listed as his own responsible party in admission records. The resident repeatedly requested access to a phone to contact his wife and daughter but was denied each time, with staff confirming these requests and their instructions to refuse them. Facility policies reviewed during the investigation stated that residents have the right to self-determination and access to communication, including telephones. The Medical Power of Attorney provided by the family only took effect if the resident was deemed unable to make decisions by a physician, which was not the case. Despite this, the facility prioritized the family member's demands over the resident's rights, resulting in the removal of communication access without appropriate legal or medical justification.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them. During an observation, Medication Cart #1 was found unlocked and unattended in the 300 Hall, outside a resident's room and across from the nurses' station, with no staff present in the immediate area. Medication Tech A, who was responsible for two medication carts that day, admitted to forgetting to lock the cart when switching between carts. The Director of Nursing (DON) confirmed the cart was found unlocked and was unsure who was responsible until Medication Tech A acknowledged it was her oversight. Interviews revealed that Medication Tech A was trained to always lock medication carts and recognized the risk of leaving them unlocked, stating that a patient could access the medications. The Administrator confirmed that staff routinely receive in-services on medication administration and the importance of keeping medication carts locked. Despite requests, the facility's policy on locked medication carts was not provided during the survey.
Failure to Ensure Timely Response to Incoming Calls and Maintain Functioning Communication Devices
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to maintain the highest practicable psychosocial well-being for 17 residents, specifically by not ensuring that calls directed to a centralized staff work area were answered and that portable phones were available and functioning. Multiple observations and interviews revealed that after hours, incoming calls to the facility were routed to nurses' stations, but staff did not consistently answer these calls. A confidential interview indicated that a resident's representative was unable to reach staff by phone on several occasions, particularly during early morning hours, to discuss concerns about the resident's care. Surveyor observations confirmed that calls to the facility went unanswered at certain times, and portable phones at the 200 hall nurses' station were missing or not functioning for an extended period. Further interviews with staff, including the receptionist, ADON, DON, and ADM, confirmed that portable phones were either misplaced or not properly charged, and that staff were expected to answer calls after hours using either land lines or portable phones. The DON and ADM acknowledged that the portable phone at the 200 hall had been missing for months and that callers could not leave messages unless they knew a direct extension. The facility's resident rights policy emphasized the importance of communication and access, but the lack of functioning phones and unanswered calls directly impacted residents' ability to communicate with the facility.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for the resident council meetings, resulting in repeated interruptions by staff and providers during the meetings. Observations showed that the meetings were held in the activities room, which is an open area without doors, allowing staff to enter and disrupt the proceedings. During one observed meeting, five care staff and providers entered the room, interrupting the group. Residents reported that staff frequently came in and out of the activities room during meetings and used the vending machines located there. Interviews with facility leadership confirmed that resident council meetings were typically held in the activities room or dining room, and that the conference room, which is a private area, was unavailable because it was used as a workspace by nurse managers. The classroom was only available if not in use for orientation. The facility's Resident Rights policy states that residents are entitled to privacy and confidentiality, but the current practice did not ensure these rights during resident council meetings.
Failure to Ensure Correct Negative Pressure Wound Device Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards for a resident with pressure ulcers, specifically regarding the use of a negative pressure wound device. The resident, an elderly female with diagnoses including heart failure, pyelonephritis, and dementia, was admitted with two stage IV pressure ulcers. Physician orders specified that the negative pressure wound device should be set to 125 mmHg. However, on two consecutive days, observations revealed the device was set at 150 mmHg instead of the ordered setting. The resident was unaware of the correct settings or when they were last changed. Interviews with nursing staff indicated a lack of clarity and oversight regarding the correct device settings. The nurse assigned to the resident was uncertain about the required settings and deferred to the treatment nurse, who then acknowledged the discrepancy and adjusted the device to the correct setting. The DON stated that it was the responsibility of the treatment nurse to ensure the settings matched physician orders and characterized incorrect settings as a medication error. Facility policy also required verification of physician orders and correct device settings, which was not followed in this instance.
Failure to Follow Food Storage and Safety Standards in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and safety standards. Specifically, foods stored in the refrigerator, such as trays of drinks and fruit cups, were found to be unlabeled and undated. In the dry storage area, an opened jug of mashed potatoes was left exposed to air, and a can of marinara sauce was found to be dented. Additionally, open items in dry storage were not properly sealed, and dented cans were not separated from other food items as required. Interviews with dietary staff and management confirmed that it was the responsibility of kitchen aides and all kitchen staff to ensure food and drinks were labeled, dated, and sealed appropriately, and to check for and separate dented cans. Staff acknowledged that failure to follow these procedures could result in residents being served expired or contaminated food and drinks. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Provide Timely Call Light Response and Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received necessary assistance with grooming and timely response to call lights. Record review showed that the resident, a female with multiple diagnoses including muscle weakness, gait abnormalities, lack of coordination, cognitive communication deficit, and end stage renal disease, required significant assistance. Interviews and documentation revealed that the resident experienced delays in care, specifically after a bowel movement when staff turned off her call light without providing the requested assistance, resulting in her remaining unclean until the following morning. Additional interviews with CNAs confirmed that call lights were sometimes turned off without care being provided, and residents expressed reluctance to use the call light due to fear of being ignored or inconveniencing staff. Staff interviews further indicated that call light response times were inconsistent, with some staff acknowledging that lights could remain unanswered for up to 15 minutes or more. The DON and Administrator confirmed that residents had complained about delayed responses and that there was no overnight manager on duty, relying instead on periodic spot checks by leadership. Review of grievance reports and facility policy corroborated that the expectation was for call lights to be answered as soon as possible, but this standard was not consistently met, resulting in unmet care needs for the resident.
Failure to Sanitize Equipment and Perform Hand Hygiene Between Resident Contacts
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by observations of a medication aide (MA G) not sanitizing a blood pressure cuff and not performing hand hygiene before resident contact. Specifically, MA G obtained a blood pressure device from an unattended medication cart and used it on a male resident with encephalopathy, cerebral infarction, pneumonia, and diabetes mellitus type II, without sanitizing the cuff or device prior to use. Later, MA G used the same device on a female resident admitted for extended rehabilitative therapy following a femur fracture and with diabetes mellitus type II, again failing to sanitize the equipment and also neglecting to perform hand hygiene before resident contact. Interviews with MA G revealed she did not recall performing hand hygiene before contact with the second resident and assumed the blood pressure cuff was sanitized before use, later acknowledging that she should have sanitized it between uses. Both the Director of Nursing (DON) and the Administrator confirmed their expectations that staff perform hand hygiene and sanitize shared equipment between resident contacts, in accordance with facility policies and in-service training records, which MA G had attended. Facility policies reviewed emphasized the importance of hand hygiene before and after resident contact and the cleaning and disinfection of reusable resident-care equipment between uses.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of a resident who was discharged home. The Administrator (ADM) and Director of Nursing (DON) directed staff to discharge a resident with a diagnosis of dementia, confusion, and altered mental status, who had no power of attorney (POA), to her home without confirming appropriate supervision or care arrangements. The Interdisciplinary Team (IDT) did not notify the nurse practitioner (NP) or physician (MD) about the resident's discharge home alone and without services. The discharge planning process did not include a thorough assessment of the resident's cognitive and functional abilities at the time of discharge, and the discharge Minimum Data Set (MDS) was incomplete and unsigned by authorized personnel. The resident's care plan indicated she required assistance with activities of daily living (ADLs), supervision for mobility and transfers, and was at risk for falls due to her cognitive impairment. Despite these documented needs, the resident was discharged via a ride-share service to an apartment that, according to family, lacked electricity and was unsanitary. The family member who was listed as an emergency contact expressed concerns about the resident's ability to live alone and the unsafe home environment, but these concerns were not adequately addressed by the facility. The facility did not ensure that home health services or necessary durable medical equipment were arranged prior to discharge, and other potential family contacts were not involved in the discharge planning process. Interviews with facility staff and family revealed that the discharge was driven by the end of the resident's insurance coverage, and the ADM did not investigate the home environment or seek alternative family support before proceeding. The resident arrived home without a walker or wheelchair and was left alone, with the family member only able to assist after the fact. The NP later confirmed that the resident's confusion was progressive and that she required supervision if discharged home. The facility's actions resulted in the resident being returned to an unsafe environment without adequate planning or support, as documented by multiple staff and family interviews.
Removal Plan
- Residents and family members will be instructed to provide their own transportation upon discharge. Courtesy transportation will no longer be provided.
- Discharge paperwork will be presented to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- A discharge summary/plan of care will be provided to the cognitively intact resident, responsible party, and/or power of attorney.
- Post discharge services such as home health will be set up prior to discharge.
- Physicians and NPs will be notified of discharges to address resident's needs.
- An in-service will be completed with the Administrator by the Regional President of Operations that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the Social Worker and Case Manager by the Administrator that details the entire discharge planning process including the completion of discharge summaries, contacting RP/POA's, confirmation of transportation, and home health set up confirmation.
- An in-service will be completed with the IDT by the Administrator regarding the completion of the discharge summary, notifying the Physicians and NPs of discharges to address resident's needs, providing discharge paperwork to the power of attorney, responsible party, and/or resident if they are their own RP with intact cognition to be reviewed and signed upon discharge.
- All discharges will be reviewed by the IDT in a weekly standards of care meeting to ensure care/summary was completed, Discharge Summary completed, signatures on the discharge summary by the appropriate party, confirmation of home health orders, and means of discharge transportation were completed.
- All residents that are not cognitively intact and do not have a Power of Attorney or Responsible Party at the time of discharge, the facility social worker and/or administrator will contact the ombudsmen and seek assistance if needed for guardianship.
- The DON/Designee will review all discharge orders for upcoming discharges for completion.
- The DON/Designee will communicate with the NP/Physician prior to discharge to address any additional post discharge needs.
- The Administrator/Designee will audit all discharges for discharge summaries, discharge location, means of transportation, and confirmation of home health.
- A Quality Assurance and Performance Improvement review of the removal plan will be completed with the Medical Director for agreement with this plan.
Failure to Include Discharge Planning in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans that included measurable objectives and timeframes for four out of ten residents reviewed. Specifically, the care plans did not address discharge goals, objectives, and interventions for these residents, despite their varied and complex medical conditions. For example, one resident with acute kidney failure, dementia, and impaired mobility had a care plan that omitted discharge planning, even though she was moderately cognitively impaired and unable to recall details about her discharge or personal belongings. Another resident, admitted for short-term skilled care following hospitalization, had diagnoses including muscle wasting, prostate cancer, and cardiac issues. Although he was cognitively intact and aware of his short-term therapy goals, his care plan did not include discharge objectives or interventions. Similarly, two other residents with significant medical histories, such as end-stage renal disease, COPD, stroke, and hemiparesis, also had care plans lacking discharge planning components, despite their imminent plans to return home with family support. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that care plans were not consistently updated to reflect discharge planning, with some staff relying on separate discharge assessments or planning by other disciplines. The facility was unable to provide a care plan policy when requested. Federal guidelines require that comprehensive care plans include measurable objectives, timeframes, and discharge planning in consultation with the resident and their representatives, which was not met in these cases.
Failure to Complete Significant Change Assessment After Resident's Cognitive Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition was comprehensively assessed within 14 days, as required. Specifically, a female resident with a history of unspecified dementia and cognitive communication deficit was readmitted to the facility and observed with increased confusion, memory loss, and altered mental status. Despite these changes, which included a decline in cognitive function and increased need for assistance with activities of daily living (ADLs), a Significant Change in Status Assessment (SCSA) was not completed. Medical records and staff interviews confirmed that the resident's cognitive status had deteriorated during her stay, with documentation of progressive dementia and acute metabolic encephalopathy. The care plan and progress notes reflected the resident's need for increased supervision and support, and staff interviews indicated that the resident required more assistance and should not have been discharged home alone. The facility's policy and CMS regulations require that significant changes in a resident's condition, especially those impacting multiple areas of health status and requiring interdisciplinary review, trigger a comprehensive assessment. Interviews with the Assistant Directors of Nursing (ADON), Nurse Practitioner (NP), and MDS nurse revealed that the expectation was for a Significant Change Assessment to be completed when a resident exhibited altered mental status or cognitive decline. The MDS nurse and DON acknowledged that the assessment was not completed as required, and that the failure could result in the resident's plan of care not being updated to reflect her current needs.
Failure in Pain Management for Resident After Fall
Penalty
Summary
The facility failed to provide adequate pain management for a resident who experienced severe breakthrough pain following an unwitnessed fall. The resident, who had a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a past pelvic fracture, was found on the floor of his room, expressing pain through yelling and grabbing his right hip. Despite the resident's evident distress, there were no documented pain assessments on the days following the fall, and the resident's care plan from a previous admission was not updated to reflect his current condition. The resident's physician had ordered Tramadol and Tylenol for pain management, but there was a delay in administering these medications. The Tramadol was never delivered, and the Tylenol was not documented as given until later in the day. The resident's family, upon visiting, found him in severe pain and requested he be sent to the emergency room, where he was diagnosed with a right hip fracture requiring surgery. Interviews with facility staff revealed communication lapses and a lack of timely intervention, with the nurse responsible for the resident's care failing to complete necessary pain assessments and neuro checks. The facility's Director of Nursing (DON) and other staff were not fully aware of the resident's condition and the lack of pain management until after the incident. The nurse practitioner was contacted for pain medication orders, but there was confusion and delay in obtaining and administering the necessary medications. The facility's failure to adequately assess and treat the resident's pain placed him at risk for unnecessary pain and discomfort, highlighting significant deficiencies in the facility's pain management practices.
Failure to Provide Adequate Post-Fall Care and Pain Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who experienced a fall, resulting in a deficiency. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, was found on the floor of his room. Despite expressing pain through yelling and grabbing his right hip, routine neuro checks were not completed following the fall. The resident's care plan, which included goals for pain management, was not adhered to, as there were no documented pain assessments on the days surrounding the incident. The resident's physician's orders included pain management medications such as Tramadol and Tylenol, with instructions to monitor pain every shift. However, these orders were not effectively followed, as evidenced by the lack of documented pain assessments and the delayed administration of pain medication. The resident continued to experience pain, leading to a family request for emergency medical attention. The resident was eventually diagnosed with a right hip fracture requiring surgery. Interviews with facility staff revealed a breakdown in communication and documentation. The LVN responsible for the resident's care admitted to not completing neuro checks, believing the resident's condition had improved. The DON and Administrator acknowledged the failure to follow up on neuro checks and pain assessments, which contributed to the resident's prolonged suffering. The facility's policies on incident reporting and investigation were not adequately implemented, resulting in the deficiency.
Failure to Document Medication and Assessments After Resident Fall
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who experienced a fall. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, did not have the administration of Tylenol Arthritis 650 MG documented on the Medication Administration Record during the morning shift. Additionally, the time of administration was not recorded in the progress notes. This lack of documentation was attributed to LVN A, who also failed to conduct and document necessary pain assessments and neuro checks following the resident's fall. On the morning of the fall, the resident was found on the floor, expressing pain and grabbing his right hip. Despite these signs, LVN A did not complete neuro checks or pain assessments throughout her shift, as the resident's vocal expressions of pain decreased. The resident's wife indicated that Tylenol could be administered for relief, which LVN A did, but failed to document it properly. The incident report was not completed until two days later, which delayed the necessary follow-up assessments and documentation. Interviews with the Director of Nursing (DON) and the Administrator confirmed that LVN A did not adhere to the facility's documentation policies. The DON emphasized the importance of timely and accurate documentation to prevent risks such as state visits or legal actions. The Administrator noted that the lack of documentation compromised the resident's assessment and care. The facility's policies on pain assessment and management, as well as medication administration, were not followed, leading to this deficiency.
Failure to Notify Family of Resident's Fall and Injury
Penalty
Summary
The facility failed to immediately notify the family member of a significant change in a resident's health status following an unwitnessed fall. The resident, a male with a history of Type 2 Diabetes, Essential Hypertension, Dementia, Heart Failure, and a History of Falling, experienced breakthrough pain after the fall. Despite the resident's evident distress and pain, the family was not informed of the incident until they arrived at the facility later that morning. The progress notes indicate that the resident was found on the floor of his room, expressing pain and grabbing his right hip. Although the nurse practitioner and the Director of Nursing (DON) were notified, the family was not informed by LVN A, who was responsible for the resident's care at the time. The family only became aware of the fall when they visited the facility and noticed the resident's condition. The family member requested the resident be sent to the emergency room due to the pain, leading to a diagnosis of a right hip fracture requiring surgery. Interviews with facility staff, including LVN A, the DON, and the Administrator, confirmed that the family was not notified as per the facility's policy. LVN A admitted to failing to inform the family, and the DON acknowledged that all staff were trained to notify the doctor, nurse management, and the family after a significant change or incident. The failure to notify the family promptly placed the resident at risk of not having an advocate and potentially delayed medical treatment.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was accessible, which is a critical intervention to prevent falls. On multiple occasions, the call light for a resident with a history of falls, mild cognitive impairment, and generalized muscle weakness was not within reach. Observations on the specified date revealed that the call light was placed in various inaccessible locations, such as across the room or behind the resident, making it impossible for the resident to use it to call for assistance. Interviews with staff, including the Director of Nursing (DON), Registered Nurse (RN), Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs), confirmed that the expectation was for call lights to be within reach at all times. Despite this, the resident's call light was repeatedly found out of reach, and staff acknowledged the importance of having the call light accessible to prevent falls. The facility's policy on answering call lights also emphasized the need for call lights to be within easy reach of residents, highlighting a failure to adhere to established procedures.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, specifically in the storage, preparation, distribution, and serving of food. During an observation in the walk-in freezer, it was found that there were two open cases of food, including frozen cookies and hamburger patties, with interior plastic bags left open. This exposed the food to ambient air, potential contaminants, freezer burn, and a decrease in quality. Additionally, a coil of sausage was found without any covering or packaging, in direct contact with a metal shelf. None of these food items were labeled or dated, which is against the facility's policy. The Dietary Manager confirmed that the facility's policy requires all food to be sealed, labeled, and dated with the received or open date and expiration or best use by date. The manager acknowledged that the food items in question were not properly sealed, labeled, or dated, which is her responsibility. The facility's policy, HSG Policy 017, and the U.S. FDA Food Code both emphasize the importance of protecting food from contamination by ensuring it is stored in packages, covered containers, or wrappings, and labeled and dated appropriately.
Inadequate Hand Hygiene by CNA During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with residents while serving meals. Specifically, CNA A was observed serving lunch trays to four residents without using hand sanitizer or washing hands between each resident interaction. This lapse in protocol occurred despite the availability of hand sanitizer in the hallway and the CNA's prior training on hand hygiene procedures. The residents involved in this deficiency included a female resident with atrial fibrillation, hypertension, and diabetes, a male resident with dementia, hypertension, and diabetes, another male resident with a history of stroke, heart failure, and diabetes, and a male resident with hypertension, depression, and hypothyroidism. These residents required assistance with activities of daily living and had varying levels of cognitive impairment. The Director of Nursing confirmed that all staff were required to perform hand hygiene after resident contact to prevent the spread of infections.
What surveyors are citing around you — mapped
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Desoto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desoto Nursing & Rehabilitation Center | 0.9 mi | ★★★★★ | 15 | 1 |
| Park Village Healthcare And Rehabilitation | 1.6 mi | ★★★★★ | 9 | 2 |
| Five Points Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 6 | 0 |
| Williamsburg Village Healthcare Campus | 3.2 mi | ★★★★★ | 36 | 5 |
| Windsor Gardens | 3.3 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.