DeSoto Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at DeSoto Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Feb 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  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. 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. […]

• No harm, potential for more than minimal, patternF677Oct 5, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF812Oct 5, 2023

  Based 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. […]