Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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 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 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.
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 | — | 8 | 2 |
| Windsor Gardens | 2.7 mi | — | 1 | 0 |
| Williamsburg Village Healthcare Campus | 2.7 mi | — | 34 | 5 |
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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 August 2026) and official state health department websites.