17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
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
109 Methodist Way, Desoto, TX
(281) 419-5520
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
2020-10-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 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
RN hours / resident day
0.57
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.39
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.49
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.07
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
3,181
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.56
Baseline 20.79% · Performance 18.86% · Measure score 5.56 · Achievement 5.56 · Improvement 4.64
Healthcare-associated infections
6.40
Baseline 6.91% · Performance 5.92% · Measure score 6.40 · Achievement 6.40 · Improvement 4.65
Total nurse turnover
2.31
Baseline 79.33% · Performance 64.00% · Measure score 2.31 · Achievement 0 · Improvement 2.31
Adjusted total nurse staffing
3.96
Baseline 4.75 hours · Performance 4.20 hours · Measure score 3.96 · Achievement 3.96 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 250 · Observed rate 10.8% · Lower 95% interval 7.12% |
| Discharge to community | 64.56% |
50.57%
14 pts better
|
Better than the National Rate · Eligible stays 236 · Observed rate 52.12% · Lower 95% interval 58.39% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.18% |
95.27%
5.1 pts worse
|
Numerator 202 · Denominator 224 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 224 |
| Discharge self-care score | 65.19% |
53.69%
11.5 pts better
|
Numerator 88 · Denominator 135 |
| Discharge mobility score | 65.19% |
50.94%
14.2 pts better
|
Numerator 88 · Denominator 135 |
| Pressure ulcers or injuries, new or worsened | 2.23% |
2.29%
0.1 pts better
|
Numerator 5 · Denominator 224 · Adjusted rate 1.83% |
| Healthcare-associated infections requiring hospitalization | 5.92% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 6.16% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 155 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.33% |
56.45%
16.9 pts better
|
Numerator 99 · Denominator 135 |
| Transfer of health information to provider | 97.52% |
95.95%
1.6 pts better
|
Numerator 157 · Denominator 161 |
| Transfer of health information to patient | 69.23% |
96.28%
27 pts worse
|
Numerator 36 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 110 |
Quality measures
| 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 | 92.9% |
97.9%
5 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 2.4% |
2.7%
0.3 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
3.3%
0.8 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.2% · Q3 4.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.2% |
18.9%
17.7 pts better
|
19.6%
18.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.7% |
10.8%
9.1 pts better
|
16.7%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · 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 | 4.5% |
15.4%
10.9 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
16.1%
7.8 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 19.0% · 4Q avg 8.3% · 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 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · 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 | 17.2% |
15.0%
2.2 pts worse
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.9% · Q3 24.0% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.2%
0.3 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.2% · Q3 3.5% · Q4 4.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.7%
9.5 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.8% · Q2 98.3% · Q3 98.8% · Q4 99.8% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.0%
4.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 8.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.0% · Q3 0.2% · Q4 0.5% · 4Q avg 0.6% · 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% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
25.9%
3.2 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 34.2% · Expected 28.0% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (5 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-06-30
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-30
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-30
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-30
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-08
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-30
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 2025-08-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-30
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-30
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 2025-06-30
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-23
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-22
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 2024-06-10
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-06-10
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-05-22
Inspection history
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 2025-12-11
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-11
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-11
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Not marked corrected
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.
Not marked corrected
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-28
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-28
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-09
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-05-09
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-09
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2025-05-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-09
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-09
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-02
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-02-02
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-06
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-16
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-31
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-06-07
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-11
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-02
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-02
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-04-02
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 2023-04-02
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-25
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 2023-04-20
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 2023-03-24
Penalties and ownership
Fine · fine $12,260
Fine
Fine · fine $15,733
Fine
Fine · fine $10,009
Fine
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Nearby options
Desoto, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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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
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