Desoto Healthcare Center

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement residents' care plans for Percutaneous Endoscopic Gastrostomy (PEG) site care (Resident #2 and Resident #9) and nail care for dependent residents' (Resident #7 and Resident #48) for four (4) of 19 care plans reviewed. Resident #2, #7, #9, and #48Findings Include: A review of the facility policy titled Comprehensive Plan of Care, revised 2/17/25, revealed under Policy: [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to provide nail care for residents who required assistance with Activities of Daily Living (ADLs) for 2 (two) of nineteen sampled residents. Resident #7 and Resident #48. Findings Include: Review of the facility policy Fingernail and Toenail Care with revision date of 05/02/22, revealed, All residents of (Proper Name) facilities shall receive nail care, on a regularly scheduled basis .2. Routine cleaning, inspection, and nail care, to include trimming and filing, will be provided on a regular schedule and as needed. Resident #7 An observation of Resident #7 on 9/15/25 at 2:59 PM revealed she was sitting in a Geri-chair in her room. Her left hand was contracted, with fingers turned inward toward the palm. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure that treatment and care were provided in accordance with professional standards of practice and physician orders by not utilizing and changing a drainage sponge at the insertion site of a Percutaneous Endoscopic Gastrostomy (PEG) tube as ordered for two (2) of three (3) residents with a PEG tube. Resident #2, and Resident #9Findings Include: A typed statement on company letterhead dated 9/17/25 and signed by the Director of Nursing (DON) revealed that the facility did not have a specific policy related to the care of PEG tubes. The facility staff are to follow the physician's orders concerning PEG tubes. [...]

Inspectors wroteBased on staff and resident interviews, record review and facility policy review the facility failed to protect a resident's right to be free from misappropriation of property for Resident #1 who was one (1) of three (3) sampled residents. Based on the facility's implementation of corrective actions taken on 10/11/24, this was determined to be Past Non-Compliance (PNC). Findings Include: Record review of the facility policy, Abuse, Neglect, and Exploitation with revision date of 10/10/22 revealed, Policy: This facility's policy is to protect each resident's health, welfare, and rights by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the possibility of cross contamination to food, as evidenced by failure to perform hand hygiene after picking up a soiled item off the floor during steam table temperature checks for one (1) of three (3) kitchen observations. Findings Include: Review of the facility policy titled Infection Prevention and Control with a revision date of 6/8/2023 revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for two (2) of 2 quarters reviewed. First and Second Quarters of 2024. Findings Include: Record review of the facility policy, Nursing Services and Sufficient Staff revised 10/12/22 revealed . Policy Explanation and Compliance Guidelines . 7. The facility is responsible for submitting timely and accurate staffing data through the CMS (Centers for Medicaid/Medicare Services) Payroll-Based Journal (PBJ) system . Record review of the PBJ (Payroll Based Journal) Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2 2024 (January 1-March 31) revealed Excessively Low Weekend Staffing Triggered. Triggered =Submitted Weekend Staffing data is excessively low. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to ensure there was a physicians order for a bolster sheet that was being used to prevent a resident from getting out of bed for one (1) of 27 residents on sample. Resident #81 Findings Include Review of the facility policy titled, Restraints with a revision date of 11/28/17 revealed . Restraint Order .orders for restraint should specify: the rationale (medical necessity) for the use of restraint, the type of restraint . An observation on 07/15/24 at 10:50 AM, revealed there was a concave mattress on Resident #81's bed and the resident was gone to dialysis. An interview on 7/16/24 at 9:00 AM, with Registered Nurse (RN) #1 revealed Resident #81 had several falls and the facility had implemented several different measures to prevent them. [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of 26 residents care plans reviewed. Resident #93 Findings Included: Record review of the facility policy titled, Comprehensive Plan of Care revised 10/10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Record review of Resident #93's care plan, date initiated 4/11/24 revealed Focus: The resident has an ADL self-care performance deficit .Interventions . [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) care was provided daily as evidenced by a resident did not receive daily oral care for one (1) of 26 residents reviewed. Resident #93. Findings Include: Record review of the facility policy Activities of Daily Living (ADL) revised 09/15/22 revealed Policy Explanation and Compliance Guidelines . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 07/15/24 at 10:55 AM, an interview with Resident #93 revealed she was admitted to the facility about three (3) months ago. She revealed the Certified Nursing Assistants (CNAs) gave her good baths, but she had a concern about her teeth not getting brushed. [...]

Inspectors wroteBased on observation, Resident Representative (RR) and staff interview, record review and facility policy review the facility failed to prevent the possibility of an accident as evidenced by a physician ordered medication being found in a resident's bed for one (1) of 27 sampled residents. Resident #52 Findings Include: Review of the facility policy titled, Medication Administration with a revision date of 6/8/23 revealed under Policy Explanation and Compliance Guidelines .#16. Observe the resident consumption of medication. An interview and observation on 07/15/24 at 11:22 AM, with the RR for Resident #52 revealed she was making her mother's bed and found a blue pill in the sheets. This observation revealed she was holding the blue pill. She stated she had called for the nurse. She stated this is not the first time she has found medicine in her mother's bed, but it has been a while. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to complete a Quarterly Minimum Data Set (MDS) resident assessment within the fourteen-day time frame for two (2) of 27 sampled residents. Resident #54 and #59 Findings Include: Record review of the facility policy titled MDS Assessments with a revision date of 6/9/2023 revealed Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity using the RAI (Resident Assessment Instrument) manual. [...]

Inspectors wroteBased on record review, interview and policy/procedure review, the facility failed to implement the comprehensive person-centered care plan for one (1) of 11 residents sampled, Resident #1. Certified Nurse Aide (CNA) #1, CNA # 2 and CNA #3 failed to follow the Activities of Daily Living (ADL) care plan to use a mechanical lift for Resident #1 and transferred her during the 7:00 AM to 3:00 PM shift on 12/28/23, manually transferring her twice and with the sit to stand lift once. Resident #1 began to display signs of pain on the 3:00 PM to 11:00 PM shift and was given an as needed Acetaminophen. The Nurse Practitioner (NP) ordered in-house X-rays on 12/29/23 due to continued pain. The in-house X-rays were negative for fractures, but it did note that Resident #1 was uncooperative during the X-rays. [...]

Inspectors wroteBased on record review, policy/procedure review and interview, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of 11 residents sampled, Resident #1. During the 7:00 AM to 3:00 PM shift on 12/28/23, Certified Nurse Aide (CNA) #1, CNA #2 and CNA # 3 transferred Resident #1, using a manual transfer twice and the sit to stand lift once. Resident #1 began to display signs of pain on the 3:00 PM to 11:00 PM shift and was given an as needed Acetaminophen. The Nurse Practitioner (NP) ordered in-house X-rays on 12/29/23 due to continued pain. The in-house X-rays were negative for fractures, but it did note that Resident #1 was uncooperative during the X-rays. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide residents an opportunity to choose a dining location as evidenced by all evening and weekend meals being served in resident rooms, for one (1) of four (4) survey days.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to store controlled medications in separately locked, permanently affixed compartments in locked refrigerators of medication storage rooms for two (2) of two (2) medication storage rooms observed.