Desert Blossom Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#103)'s medication was not left at bedside and resident was assessed for self-administration of medication. The deficient practice could place resident's safety at risk.Findings include:Resident #103 was admitted to the facility on [DATE] with diagnoses that included dementia, Obstructive Sleep Apnea (OSA), depression, heart failure, and chronic kidney disease.A review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14.0, indicating cognitively intact.The care plan dated November 13, 2025, revealed resident was at risk for impaired cognitive function/dementia or impaired thought processes related to new admission. The interventions included keep routine consistent to decrease confusion, monitor/document/report to provider and to the nurse any changes in cognitive function specifically changes in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility records, staff interviews, and facility policy, the facility failed to ensure that that an allegation of abuse was reported as required. Findings include:-Resident #100 was admitted on [DATE] with diagnoses of Major Depressive Disorder, difficulty walking, and type 2 Diabetes Mellitus.An annual Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact. This document included that this resident required supervision for all activities of daily living.-Resident #12 was admitted on [DATE] with diagnoses of Major Depressive Disorder, hemiparesis and hemiplegia.A quarterly Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively severely impaired with fluctuating inattention and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene.An intake for a facility reported incident received September 16, 2022 included that resident #12 was the resident involved and that previous complaints states…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and policy review, the facility failed to ensure one of three residents (#62) received services that met professional standards in regards to his medications being administered per provider order. This deficient practice could lead to medical complications.Findings include:Resident #62 was admitted on [DATE], with diagnoses that included bacteremia, urinary tract infection, sepsis and sacral decubitus.A provider order was written on April 7, 2025, for Ceftaroline Fosamil (an antibiotic), 400 milligrams intravenously (IV) every 8 hours for sepsis for 29 days. The first dose of the medication was scheduled to be administered the night of the resident's admission on [DATE].Review of Resident #62's Medication Administration Record (MAR), dated April 2025, revealed a code of 7 for the following scheduled IV doses: April 7, 2025 at 8:00 PM, April 8, 2025 at 8:00 AM and 2:00 PM, April 9, 2025 at 2:00 PM and April 10, 2025 at 8:00 AM. A code of 7 was defined in the MAR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure that 1 out of 10 sampled residents (# 41) received pain medication as ordered by the physician. The deficient practice could result in the potential for the resident to be in unnecessary pain.Findings include: Resident #41 was admitted on [DATE], with diagnoses that included fracture of the pelvis without disruption of the pelvic ring, fall from a roof, pain in the right shoulder, and muscle weakness.Review of the Resident's care plan revealed that Resident # 41 is currently prescribed an opioid for pain, effective September 11, 2023, with an intervention task that included to administer opioid medication as prescribed. Review of Resident's # 41 Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed that Resident # 41 was on Opioids for pain, which he received occasionally, and rated his pain level an 8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 out of 10 sampled residents (# 41). The deficient practice could result in the potential for the resident to not being properly medicated. Findings include: Resident # 41 was admitted on [DATE] with diagnoses that included fracture of the pelvis without disruption of the pelvic ring, fall from a roof, pain in the right shoulder, and muscle weakness.Review of the Resident's care plan revealed that Resident # 41 is currently prescribed an opioid for pain, effective September 11, 2023, with an intervention task that included to administer opioid as prescribed. Review of Resident's # 41 Minimum Data Set (MDS) dated [DATE] revealed a BIMS of 15, which indicates the resident is cognitively intact. The MDS revealed that Resident # 41 was on opioids for pain, which he received occasionally and rated the pain an 8 out of 10 over the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, facility document reviews, and facility policy, the facility failed to ensure a comfortable and safe temperatures were maintained in one resident room (Resident #274). The deficient practice could place the resident's at risk for safety and illness. Findings included: Resident #274 was admitted on [DATE] with diagnoses of osteomyelitis, urinary tract infection, chronic systolic heart failure. The resident's Brief Interview for Mental Status (BIMS) dated May 1, 2024 revealed a score of 15 that indicated resident was cognitively intact. During an initial screening on May 6, 2024 at 9:34 AM, Resident #68 stated that the room was hot, she had been in that same room for a month, and staff were aware of her concerns. Resident #68 added that the second week she got there that she almost passed out. She stated she was not used to hot temperatures since she was living in a different state. She further added that the staff brought her lots of ice and cool rags because she was very hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure medication services are provided according to accepted standards of clinical practice for one resident (#177). The deficient practice could place residents at risk for developing illness. Findings included: Resident #177 was admitted at the facility on April 18, 2024 with diagnoses of acute on chronic systolic congestive heart failure, generalized edema, and acute kidney failure. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which meant the resident was cognitively intact. Review of Resident #177 care plan initiated on April 18, 2024 revealed a focus for potential fluid deficit related to diuretic use. The goals included that the resident will be free of symptoms of dehydration and will maintain moist mucous membranes, good skin turgor. The interventions included to administer medications as ordered. On May 7, 2024 at 7:23 AM the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure staff provided meals according to regulations to one resident (#76). The deficient practice could result in residents not meeting dietary needs. Findings include: Resident #76 was admitted to the facility on [DATE] and discharged on 4/27/2023 with diagnoses that included left tibia fracture, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease. Resident #76 had an order dated 4/15/2023 for regular diet with regular texture and thin liquids. There were also orders for once daily dietary supplements; Glucerna 8 ounces and Prostat 30 milliliters, dated 4/19/202 and 4/22/2023 respectively. Medicare Minimum Data Set (MDS) dated [DATE] shows Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment. The care plan initiated on 4/16/2023 reflected a goal related to resident being malnourished. The goal for resident #76 was to maintain adequate nutritional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure nursing documentation reflect care and medical services provided for Resident # 36 according to professional standards. The deficient practice may result in incomplete and/or inaccurate clinical records, and suboptimal care due to the absence of pertinent clinical information. Findings include: Resident # 36 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism, depression, and generalized anxiety disorder. The comprehensive minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, which indicated the resident was cognitively intact. On May 06, 2024 at 10:02 AM, an observation of Resident # 36 revealed discoloration surrounding her left eye darkened at an unknown stage of bruising. An interview conducted with Resident # 36 stated that this was due to a recent fall injury inside the facility which resulted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, interviews, and policy, the facility failed to ensure that medications were available as ordered for one resident (#261). The deficient practice could result in residents not receiving needed medications. Findings include: Resident #261 was admitted to the facility on [DATE] with diagnoses that included dementia, heart disease, encephalopathy, hypotension, breast cancer, and lung cancer. The resident's pain care plan, dated 1/29/22, revealed a goal to manage pain related to cancer and risk of impaired cognition related to dementia. Review of the physician's orders dated 1/30/22 revealed an order for anastrozole (used to treat breast cancer) 1 milligram (mg) per day. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating cognitive impairment. Review of the Medication Administration Record (MAR) for January and February 1 through 8, 2022 revealed that the resident did not receive the anastrozole…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed clinical record review, interviews, and policy, the facility failed to ensure continence care was adequately documented for one resident (#266). The deficient practice could result in residents' clinical records not being accurate and complete. Findings include: Resident #266 was admitted to the facility on [DATE] with diagnoses that included fracture of right leg, dislocation of a joint in right foot, epilepsy, dementia, and major depressive disorder. The resident's incontinence care plan, dated 1/19/22, revealed the resident had bowel and bladder incontinence with the goal to remain free from skin breakdown. Interventions included washing and drying perineum and changing clothing as needed after incontinence episodes. A bowel and bladder evaluation dated 1/22/22 showed that the was always incontinent of bowel and bladder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.