Desoto Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview and review record the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #7) reviewed for ADL Care. The facility failed to provide Resident #7 with scheduled showers between 05/07/2026 - 05/20/2026. This failure could place residents at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain 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 for 1 of 5 residents (Residents #9) reviewed for infection control. LVN A failed to put on a gown and mask prior to assisting Resident #9 who vomited. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.

Inspectors wroteBased on observation and interviews, the facility failed to provide a safe, functional, sanitary environment and comfortable environment for residents, staff and the public for 1 of 3 unoccupied resident room air condition unit reviewed for environment. The unoccupied resident room air conditioning was detached from the wall and exposed outside. This deficient practice could place residents at risk of pests, exposure to the outside elements, pest and an unpleasant environment.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services as ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #7) of two residents reviewed for labs. The facility failed to obtain urinalysis (UA) for Resident #7 as ordered by physician on 02/25/2026. This failure could place residents at risk of a delay in receiving the necessary treatments to treat their medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that were accurately documented for 1 of 7 residents (Residents #2) reviewed for medical records. The facility failed to document at least once per shift that the task turn/reposition for Resident #2 was completed. This failure could place residents at risk of developing skin breakdowns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident #1) of five residents was properly supervised when Resident #1 eloped from the facility on 1/17/2026 at approximately 4:30 a.m. The facility failed on 1/17/26 to ensure Resident #1 received adequate supervision to ensure that residents were not exposed to possible hazards or injury when Resident #1 eloped from the facility and wandered toward a bridge over an active creek, which could have led to possible injuries. An immediate jeopardy existed from 1/17/26 4:30 a.m. to 1/17/26 5:00 a.m. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, hospitalization, and death.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one (Resident #39) of five residents, reviewed for pharmacy services. The facility failed to ensure LVN C and LVN H documented administration of morphine at the time of administration to Resident #39 on the MAR and the narcotic record. The facility failed to ensure LVN D, LVN E, RN F, and LVN G documented administration of morphine at the time of administration on the medication administration record for Resident #39. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure that temperatures for food items stored in a reach-in freezer had been logged twice daily and that there was an additional thermometer in the freezer to ensure accurate readings.2. The facility failed to ensure ice scoops were stored in a manner that protected against dust contamination and/or mold/mildew build up for the facilities only ice-machine. These failures could place residents at risk for food borne illness. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #29) of three residents reviewed for care plans. The facility failed to ensure Resident #29 had a comprehensive care plan for pain. This failure could place residents at risk of staff not knowing how to care for their pain.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain 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 for two (Resident #41 and Resident #8) of five residents, reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #41. The facility failed to ensure LVN B performed hand hygiene during wound care for Resident #8. These failures could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident has the right to privacy for 1 of 4 residents (Resident #1) reviewed for privacy and confidentiality: The facility failed to ensure CNA A provided privacy when providing Resident #1 with incontinent care. The door was left open to the hallway, and the privacy curtains were not closed properly. as CNA A began to uncover Resident #1, exposing his body to the open hallway. This failure could place residents at risk for a loss of privacy, emotional distress, and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain 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 for one (CNA A) of two staff observed for infection control. CNA A failed to change their soiled gloves and wash hands during incontinent care to Resident #1. This failure could place residents at risk of the spread of infection through cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended, in the memory care unit, on 07/15/2025. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of three (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three ( #2, #16, #71) of 8 residents reviewed for ADL care. The facility failed to ensure Residents' (#2, #16, #71) hair was cut and combed, faces shaved, and fingernails clipped. These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decrease their dignity which could lead to a decreased psycho-social well-being and feeling of self worth.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for food storage and kitchen sanitation. 1. The facility failed to adequately clean the kitchen which resulted in an accumulation of food and dirt on the equipment surfaces and appliances. 2. The facility failed to clean the kitchen and floors thoroughly and replace the dish racks that were old, discolored, chipped and appeared unclean. These failures could place residents at risk for ingesting cross contaminated food, which could result in food-borne illnesses, health decline and serious illness. Findings Included: [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 1 of 3 residents (Resident #1). The facility failed to maintain medical records for Resident #1's progress notes from his mental health visit on 8/18/23 that were complete and accurate until 10/05/23. This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay.

Inspectors wroteBased on observations, interviews and record reviews the facility failed the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences of two (Residents #13 and #35) of 8 residents reviewed for accommodation of needs and preferences. The facility failed to ensure Resident #13 and #35 personal hair care needs were addressed. These failures could cause residents to be at risk of having a loss of dignity and self-worth which could cause a decline in their psycho-social and physical well-being.