Desoto Retirement & Rehab Ctr, LLC

In the surveyor’s words

From the most serious findings on record at Desoto Retirement & Rehab Ctr, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF921Aug 26, 2026

  Based on record review, observations, and interviews the facility failed to provide a sanitary, comfortable, and homelike environment for residents, staff and the public by failing to:1. Remove and replace stained/discolored ceiling tiles, and2. Maintain HVAC ventilation grilles. Findings:Review of the facility's undated Resident Rights policy revealed, in part:.The resident has a right to a safe, clean, comfortable and homelike environment. Observation on 08/25/2026 at 8:35 a.m. revealed front lobby HVAC grille appeared moist, had peeled paint, and had gray/black discoloration. Observation on 08/25/2026 at 8:45 a.m. revealed locked unit lobby HVAC grille had gray/black discoloration, peeled paint and ceiling tile next to HVAC grille had gray/black discoloration. […]

• No harm, potential for more than minimal, patternF644Apr 22, 2026

  Based on record review and interviews, the facility failed to refer 1 (#3) of 1 resident with a new diagnosis of schizoaffective disorder for a Level II PASARR.Findings:Review of Resident #3's medical record revealed an admit date of 02/15/2023 with the following diagnoses, including in part: unspecified psychosis not due to a substance or known physiological condition, unspecified mood (affective) disorder. Further review revealed a new diagnosis of schizoaffective disorder dated 12/15/2023.Review of Resident #3's medical record failed to reveal a Level II PASARR referral was completed for a new diagnosis of schizoaffective disorder.During an interview on 04/22/2026 at 10:00 a.m., S1Social Services Director confirmed Resident #3 was admitted on [DATE] and Resident #3 had a new diagnosis… […]

• No harm, potential for more than minimal, patternF600Dec 8, 2025

  Based on record reviews, observations, and interviews the facility failed to protect resident's right to be free from verbal abuse by a staff member for 1 (Resident #2) of 3 sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.Findings: Review of the facility's Abuse Prevention and Intervention Policy (undated) revealed in part:Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Verbal Abuse means the use of oral, written or… […]

• No harm, potential for more than minimal, patternF609Dec 8, 2025

  Based on record reviews and interviews the facility failed to complete required reporting to the State Survey Agency in accordance with State law in a timely manner for 1 (Resident #2) of 2 sampled residents who required reporting to be submitted. The facility failed to report an allegation of verbal abuse from a staff member to Resident #2 within 2 hours after the allegation was made.Findings: Review of the facility's Abuse Prevention and Intervention Policy (undated) revealed in part:Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Verbal Abuse means… […]

• No harm, potential for more than minimal, patternF641Feb 19, 2025

  Based on record review and interview the facility failed to ensure resident's assessments accurately reflected the resident's status during the observation period for 3 (#5, #21, #50) of 18 (#5, #15, #21, #22, #24, #28, #35, #38, #41, #43, #49, #50, #58, #63, #66, #67, #118, #119) residents reviewed for assessment. The facility failed to ensure the MDS (Minimum Data Set) were coded accurately for restraints and use of bedrails. Findings: Resident #5 Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses that include in part, major depressive disorder, anxiety disorder, pain and paranoid schizophrenia. […]