Cycle 1
Health 2025-09-18 · Fire 2025-09-18
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Southaven, MS
Desoto Healthcare Center
3-star overall rating with 3-star inspections with $9,318 in total fines with 3 recent health deficiencies
7805 Southcrest Parkway, Southaven, MS
(662) 349-7500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care Management
Operator or chain grouping
Approved since
2003-02-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,863
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.30
Composite VBP score used to determine payment impact.
Payment multiplier
1.0008
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.04
Baseline 29.19% · Performance 21.24% · Measure score 6.04 · Achievement 0 · Improvement 6.04
Healthcare-associated infections
1.49
Baseline 12.20% · Performance 10.77% · Measure score 1.49 · Achievement 0 · Improvement 1.49
Total nurse turnover
6.37
Baseline 33.75% · Performance 37.63% · Measure score 6.37 · Achievement 6.37 · Improvement 0
Adjusted total nurse staffing
5.03
Baseline 3.77 hours · Performance 4.51 hours · Measure score 5.03 · Achievement 5.03 · Improvement 3.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.23% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 11.89% · Lower 95% interval 7.95% |
| Discharge to community | 59.04% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 50.63% · Lower 95% interval 51.59% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.85% |
95.27%
2.6 pts better
|
Numerator 182 · Denominator 186 |
| Falls with major injury | 2.69% |
0.77%
1.9 pts worse
|
Numerator 5 · Denominator 186 |
| Discharge self-care score | 57.84% |
53.69%
4.2 pts better
|
Numerator 59 · Denominator 102 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 68 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 1.62% |
2.29%
0.7 pts better
|
Numerator 3 · Denominator 185 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 10.77% |
7.12%
3.6 pts worse
|
Worse than the National Rate · Eligible stays 176 · Observed rate 15.34% · Lower 95% interval 7.44% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 154 |
| Staff flu vaccination coverage | 29.93% |
42%
12.1 pts worse
|
Numerator 44 · Denominator 147 |
| Discharge function score | 67.65% |
56.45%
11.2 pts better
|
Numerator 69 · Denominator 102 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 85 · Denominator 85 |
| Resident COVID-19 vaccinations up to date | 8.6% |
25.2%
16.6 pts worse
|
Numerator 8 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.4
0.6 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.9
1.7 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.2%
0.1 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.1% · Q3 2.8% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.6%
1.2 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
6.1%
3.3 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.6% · Q3 3.3% · Q4 3.3% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
24.4%
6.2 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 27.7% · Q3 31.7% · Q4 32.8% · 4Q avg 30.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.2% |
23.4%
6.2 pts better
|
16.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 19.1% · Q4 16.3% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.2%
0.1 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 37.5% |
22.8%
14.7 pts worse
|
16.3%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
20.6%
10 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.5% · Q2 24.2% · Q3 29.5% · Q4 30.0% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.5%
1.1 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 1.6% · Q4 6.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.5%
2.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.0% |
21.4%
3.4 pts better
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 20.8% · Q3 12.7% · Q4 12.1% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
6.9%
4.1 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 14.0% · Q3 6.2% · Q4 9.9% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
87.9%
9.9 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 97.0% · Q3 99.0% · Q4 99.0% · 4Q avg 97.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
15.3%
9.7 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.6%
0.5 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.1% · Q3 3.3% · Q4 2.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
84.6%
11.6 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.2% |
27.9%
4.3 pts worse
|
23.9%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 30.7% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2024-07-18
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-19 · Fire 2023-04-19
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-09-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-20
D · Potential for more than minimal harm
2025-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-20
D · Potential for more than minimal harm
2024-11-25
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-07-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-26
F · Potential for more than minimal harm
2024-07-18
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-26
D · Potential for more than minimal harm
2024-07-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-26
B · Minimal harm
2024-07-18
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-26
G · Actual harm
2024-01-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-02
G · Actual harm
2024-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-08-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-10
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-04-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-04-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-22
Penalties and ownership
What sits behind the stars
$9,318
2024-01-30
Fine
Fine · fine $9,318
Fine
Ownership
Desoto Healthcare Inc
5% Or Greater Direct Ownership Interest · Organization
Cain, Brian
5% Or Greater Indirect Ownership Interest · Individual
Griffin, Troy
5% Or Greater Indirect Ownership Interest · Individual
Hubbard, Gene
5% Or Greater Indirect Ownership Interest · Individual
Tice, Richard
5% Or Greater Indirect Ownership Interest · Individual
Griffin, Troy
Corporate Officer · Individual
Hubbard, Gene
Corporate Officer · Individual
Tice, Richard
Corporate Officer · Individual
Tice, Richard
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Diversicare Of Southaven
Southaven, MS
1-star overall rating with 1-star inspections with $59,175 in total fines with 12 recent health deficiencies
#2
Landmark Of Desoto
Horn Lake, MS
2-star overall rating with 2-star inspections with $10,527 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Graceland Rehabilitation And Nursing Care Center
Memphis, TN
1-star overall rating with 1-star inspections with Special Focus status with $342,603 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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