Cycle 1
Health 2025-05-29 · Fire 2025-05-29
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Desoto, TX
Five Points Nursing And Rehabilitation
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
1901 N. Hampton Rd., Desoto, TX
(972) 694-9810
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2021-12-01
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
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.07
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Performance 72.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.70 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.62% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 6.57% |
| Discharge to community | 41.86% |
50.57%
8.7 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 29.79% · Lower 95% interval 29.64% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · 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 20 · 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 109 |
| Staff flu vaccination coverage | 45.98% |
42%
4 pts better
|
Numerator 80 · Denominator 174 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · 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 | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 3.4% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
3.3%
2.8 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.8% |
18.9%
9.1 pts better
|
19.6%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 10.3% · Q3 9.4% · Q4 10.0% · 4Q avg 9.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
10.8%
3.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 10.9% · Q3 6.7% · Q4 6.2% · 4Q avg 7.2% · 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 | 16.2% |
15.4%
0.8 pts worse
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 8.4% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
16.1%
1 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 13.5% · Q3 13.3% · Q4 12.0% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
15.0%
0.6 pts better
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 10.4% · Q3 13.6% · Q4 12.2% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.2%
1.4 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.3% · Q3 2.6% · Q4 4.9% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
89.7%
8.1 pts better
|
81.7%
16.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| 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 · Q1 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 | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-02
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-02
F · Potential for more than minimal harm
2024-04-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-04-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-04-19
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 2024-04-20
F · Potential for more than minimal harm
2023-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Not marked corrected
E · Potential for more than minimal harm
2025-12-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Not marked corrected
F · Potential for more than minimal harm
2025-05-29
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 2025-06-02
E · Potential for more than minimal harm
2025-05-29
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-06-02
E · Potential for more than minimal harm
2025-05-29
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 2025-06-02
D · Potential for more than minimal harm
2025-05-29
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 2025-06-02
E · Potential for more than minimal harm
2025-03-13
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-03-17
E · Potential for more than minimal harm
2025-01-16
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-01-24
D · Potential for more than minimal harm
2025-01-16
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-24
E · Potential for more than minimal harm
2024-04-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-04-19
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-19
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 2024-04-30
D · Potential for more than minimal harm
2024-04-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-01-04
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 2024-02-01
E · Potential for more than minimal harm
2023-09-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-08
J · Immediate jeopardy
2023-08-17
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 2023-06-06
K · Immediate jeopardy
2023-02-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-23
E · Potential for more than minimal harm
2023-02-23
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 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-23
D · Potential for more than minimal harm
2023-02-23
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 2023-03-23
D · Potential for more than minimal harm
2023-02-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-23
Penalties and ownership
What sits behind the stars
$8,514
2023-08-17
Fine
Fine · fine $8,514
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
De Soto I Enterprises, LLC
Operational/Managerial Control · Organization
Huggins, Linda
Corporate Director · Individual
Thompson, Johnny
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Desoto Nursing & Rehabilitation Center
Desoto, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Williamsburg Village Healthcare Campus
Desoto, TX
2-star overall rating with 2-star inspections with abuse icon flag with $85,161 in total fines with 25 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Lennwood Nursing And Rehabilitation
Dallas, TX
1-star overall rating with 2-star inspections with $29,969 in total fines with 5 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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