Cycle 1
Health 2024-11-21 · Fire 2024-11-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Desoto, TX
Desoto Nursing & Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1101 N Hampton Rd, Desoto, TX
(972) 223-3944
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
1992-02-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 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
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.99% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 12.9% · Lower 95% interval 7.12% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 17.02% |
42%
25 pts worse
|
Numerator 24 · Denominator 141 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 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% |
97.9%
2.1 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
18.9%
6.5 pts better
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.3% · Q3 12.5% · Q4 11.7% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
10.8%
1.5 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 11.9% · Q3 10.3% · Q4 5.3% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
15.4%
0.3 pts worse
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 31.9% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
16.1%
4.5 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 7.1% · Q3 5.6% · Q4 19.0% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
15.0%
1.8 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 14.1% · Q3 15.5% · Q4 11.9% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.2%
2.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.8% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
89.7%
6.7 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 92.9% · Q3 93.2% · Q4 100.0% · 4Q avg 96.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.6% |
88.0%
4.6 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
5 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-11-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-21
F · Potential for more than minimal harm
2023-10-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-17
F · Potential for more than minimal harm
2023-10-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-08-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-08-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-24
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-11-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-07-15
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 2025-08-06
D · Potential for more than minimal harm
2024-05-16
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 2024-06-07
E · Potential for more than minimal harm
2023-10-05
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 2023-10-29
E · Potential for more than minimal harm
2023-10-05
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 2023-10-29
E · Potential for more than minimal harm
2023-10-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-29
E · Potential for more than minimal harm
2022-08-11
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 2022-09-02
D · Potential for more than minimal harm
2022-08-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-11
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 2022-09-02
D · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-02
Penalties and ownership
What sits behind the stars
Ownership
Desoto Ii Enterprises, LLC
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
5% Or Greater Indirect Ownership Interest · Individual
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
5% Or Greater Indirect Ownership Interest · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Clanton, Auston
Operational/Managerial Control · Individual
Creative Solutions In Healthcare Inc
Operational/Managerial Control · Organization
Desoto Ii Enterprises, LLC
Operational/Managerial Control · Organization
Eamiguel, Christopher
Operational/Managerial Control · Individual
Honor X Enterprises, LLC
5% Or Greater Indirect Ownership Interest · Organization
Huggins, Linda
Operational/Managerial Control · Individual
Willig, Zachary
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Methodist Transitional Care Center-Desoto LLC
Desoto, TX
2-star overall rating with 1-star inspections with $38,002 in total fines with 17 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Five Points Nursing And Rehabilitation
Desoto, TX
3-star overall rating with 3-star inspections with $8,514 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Park Village Healthcare and Rehabilitation
Desoto, TX
2-star overall rating with 1-star inspections with abuse icon flag with $266,405 in total fines with 22 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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