Cycle 1
Health 2025-06-27 · Fire 2025-06-27
17 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Desoto, TX
Methodist Transitional Care Center-Desoto LLC
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
Facility snapshot
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
Staffing
Hours and turnover
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
1.39
Licensed practical nurse staffing
Aide hours / resident day
2.49
Nurse aide staffing
Weekend hours
4.00
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-17 · Fire 2024-05-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-27
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
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 2025-08-08
E · Potential for more than minimal harm
2025-06-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-06-27
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 2025-06-30
F · Potential for more than minimal harm
2024-05-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-05-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-23
F · Potential for more than minimal harm
2024-05-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-05-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-05-17
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 2024-06-10
E · Potential for more than minimal harm
2024-05-17
K223 · Egress Deficiencies
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
E · Potential for more than minimal harm
2024-05-17
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-05-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-10
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 2025-12-11
D · Potential for more than minimal harm
2025-12-10
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 2025-12-11
D · Potential for more than minimal harm
2025-12-10
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-12-05
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Not marked corrected
D · Potential for more than minimal harm
2025-12-05
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.
Not marked corrected
E · Potential for more than minimal harm
2025-06-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-06-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-28
E · Potential for more than minimal harm
2025-06-27
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 2025-06-28
E · Potential for more than minimal harm
2025-06-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-06-28
D · Potential for more than minimal harm
2025-06-27
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 2025-06-28
D · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
J · Immediate jeopardy
2025-05-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-05-09
J · Immediate jeopardy
2025-05-08
F661 · Resident Assessment and Care Planning Deficiencies
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
J · Immediate jeopardy
2025-05-08
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-05-08
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-05-08
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 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-05-09
K · Immediate jeopardy
2025-02-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-02-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-02
E · Potential for more than minimal harm
2025-02-05
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 2025-02-02
D · Potential for more than minimal harm
2025-02-05
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 2025-02-06
D · Potential for more than minimal harm
2024-07-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-16
E · Potential for more than minimal harm
2024-05-17
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 2024-05-31
E · Potential for more than minimal harm
2024-05-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
D · Potential for more than minimal harm
2023-06-06
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-10
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 2023-04-11
E · Potential for more than minimal harm
2023-04-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-02
E · Potential for more than minimal harm
2023-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-02
D · Potential for more than minimal harm
2023-04-01
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 2023-04-02
D · Potential for more than minimal harm
2023-04-01
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 2023-04-02
E · Potential for more than minimal harm
2023-03-23
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 2023-03-25
D · Potential for more than minimal harm
2023-03-23
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 2023-04-20
D · Potential for more than minimal harm
2023-03-23
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 2023-03-24
Penalties and ownership
What sits behind the stars
$12,260
2025-05-08
Fine
Fine · fine $12,260
Fine
$15,733
2025-02-05
Fine
Fine · fine $15,733
Fine
$10,009
2023-03-23
Fine
Fine · fine $10,009
Fine
Ownership
Culp, Roland
5% Or Greater Indirect Ownership Interest · Individual
Pico, Ana
5% Or Greater Indirect Ownership Interest · Individual
Daspit, Laurence
5% Or Greater Indirect Ownership Interest · Individual
Prince, Derek
5% Or Greater Indirect Ownership Interest · Individual
Anthamatten, Dustin
Corporate Officer · Individual
Balsamo, Krystal
Operational/Managerial Control · Individual
Cibc Bank Usa
5% Or Greater Direct Ownership Interest · Organization
Cibc Bank Usa
Operational/Managerial Control · Organization
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Daspit, Laurence
Corporate Officer · Individual
Davis, Georgette
Operational/Managerial Control · Individual
Desoto Rehabilitation Institute LLC
Operational/Managerial Control · Organization
Dohn, William
Operational/Managerial Control · Individual
Forvis Mazars Llp
5% Or Greater Direct Ownership Interest · Organization
Forvis Mazars Llp
Operational/Managerial Control · Organization
Global Prime Health, LLC
Operational/Managerial Control · Organization
Hmg Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Laukaitis, Frances W
Corporate Officer · Individual
Methodist Hospitals Of Dallas
5% Or Greater Direct Ownership Interest · Organization
Methodist Hospitals Of Dallas
Operational/Managerial Control · Organization
Methodist Transitional Care Center-Desoto LLC
5% Or Greater Direct Ownership Interest · Organization
Methodist Transitional Care Center-Desoto LLC
Operational/Managerial Control · Organization
Perkins, Catina
Operational/Managerial Control · Individual
Pico, Ana
Operational/Managerial Control · Individual
Prince, Derek
Operational/Managerial Control · Individual
Reinarz, Christian
Operational/Managerial Control · Individual
Vega, Brandi
Operational/Managerial Control · Individual
Zions Bancorporation
5% Or Greater Direct Ownership Interest · Organization
Zions Bancorporation
Operational/Managerial Control · Organization
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
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
#3
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
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