DeSoto Nursing & Rehab: Repositioning Gaps Risk Bedsores - TX
The gaps appeared in the electronic health record for April 2026. On the night of April 17, she was not documented as turned. The same on the nights of April 19 and April 20. On April 28, both the second and third shifts had no record of the task being completed. Her care plan required staff to turn and reposition her at least every two hours.
The resident, identified only as Resident #2 in the report, was assessed as needing substantial to maximal staff assistance to reposition to her back, left side, and right side. She had moderate problems with memory and thinking. Her diagnoses included dementia, coronary artery disease, and rheumatoid arthritis. She arrived at the facility with two stage three pressure ulcers and one stage four already documented on admission.
A stage four pressure ulcer is the most severe classification, reaching through skin and tissue to muscle or bone. Her care plan goal was direct: the wounds would show signs of healing and remain free from infection.
CNA A, who spoke with inspectors on April 29, explained how the documentation system was supposed to work. Aides checked and changed residents every two hours, and during that time they turned and repositioned them. They were required to chart it at least once per shift in the electronic health record. She said that if the charting wasn't there, it meant one of two things: the staff member forgot to document it, or the staff member never did it. Either way, she said, the risk to the resident was skin breakdown.
LVN B put it more simply. "If it was not charted it did not happen."
The director of nursing said the same thing when inspectors interviewed her on April 30. The expectation was repositioning every two hours, charting once per shift, and if the electronic record showed nothing, the task wasn't performed. The administrator echoed her exactly: "If it is not documented it did not happen."
Four people at the facility, from a front-line aide to the administrator, gave inspectors the same answer about what missing documentation means. None of them offered an explanation for why the records were blank on those five shifts.
When inspectors asked the administrator to provide the facility's written policy on turning, repositioning, and incontinence care documentation, she said she would send it by email. It never arrived before inspectors left the building.
Inspectors did observe the resident in the common area on April 29 and again on April 30. On the second visit, she told inspectors that staff did check and change her and reposition her. That statement, recorded in the report, does not account for the five shifts where no one wrote anything down.
The inspection was conducted as a complaint investigation. The violation was cited at the level of minimal harm or potential for actual harm, affecting a small number of residents. One resident was identified.
Pressure ulcers at the stage three and stage four level do not appear overnight. They develop when tissue is compressed against a surface for too long, cutting off circulation. For a resident who cannot reposition herself and depends entirely on staff to move her, every undocumented shift is an interval that cannot be verified, and cannot be corrected after the fact.
Her care plan said the wounds would heal. Whether anyone turned her on the nights of April 17, 19, and 20, or during the evening and overnight hours of April 28, is something the facility's own records cannot answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Desoto Nursing & Rehabilitation Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
DESOTO NURSING & REHABILITATION CENTER in DESOTO, TX was cited for violations during a health inspection on April 30, 2026.
The gaps appeared in the electronic health record for April 2026.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.