Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Desert Blossom Health & Rehab Center during CMS and state inspections, most recent first.
A resident with dementia and other chronic conditions was found with a medication cup containing half of a pink pill resembling Benadryl on the bedside table, without staff present. An LPN removed the pill and confirmed there was no Benadryl order in the electronic record at that time. Later MAR review showed same-day transcription and change of a PRN Diphenhydramine order, but there was no prior documented, complete provider order or MAR entry corresponding to the earlier administration described by the DON, which had been based on a vague text message saying “Yeah prn” without dose, frequency, time, or route. The resident’s care plans addressed cognitive and psychosocial issues but did not include a self-administration of medication plan, and staff interviews and facility policies confirmed that medications should not be given without a full provider order, must be documented in the eMAR/MAR, and should not be left at the bedside unless there is a formal self-administration order and assessment.
A resident with severe cognitive impairment reported being inappropriately touched by another resident. Although the incident was documented by staff and reported internally, there was a delay in notifying external authorities as required by policy. Staff interviews confirmed the expectation for immediate reporting, but the delay was attributed to an agency nurse not following procedures.
A resident with multiple infections did not receive several scheduled doses of IV antibiotics as ordered, and there was no documentation that the provider was notified about the missed doses. Nursing staff and the DON confirmed that provider notification was required but not completed or documented, contrary to facility policy.
A resident in need of pain management did not receive safe and appropriate pain management services as required.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with a full code status and advanced directive for resuscitation was found unresponsive and did not receive CPR as required. Staff were unclear about the resident's code status, and no code was called before EMS arrived and pronounced the resident deceased. Facility policy and procedures for code response and documentation were not followed.
A resident with multiple health conditions was not documented as receiving meals on two occasions, despite having a care plan to address malnutrition. Staff interviews revealed that meal provision should be recorded in the EHR, but discrepancies were found, indicating a lapse in care or documentation.
Medication Left at Bedside Without Complete Order or Self-Administration Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were properly ordered, documented, and stored, and that a resident was appropriately assessed and care planned for self-administration of medication. A resident with dementia, OSA, depression, heart failure, and chronic kidney disease was admitted with an MDS BIMS score of 14, indicating cognitive intactness. The resident’s care plans addressed risks related to impaired cognitive function/dementia and psychosocial well-being, including monitoring for changes in cognition and side effects of psychotropic medications, but there was no care plan addressing self-administration of medications. On the morning of December 14, 2025, the resident was observed lying in bed with a medication cup on the bedside table containing a small rectangular pink pill. An LPN identified the pill as half a tablet that looked like Benadryl. When asked, the resident told the nurse not to take her Benadryl, and the LPN removed the cup from the bedside. The LPN then checked the electronic clinical record and did not find an order for Benadryl. The LPN informed the RN assigned to the resident, who stated he had not left the medication and was not aware of any Benadryl order. The RN disposed of the pill in the sharps container and stated he would notify the provider about the Benadryl. Review of the MAR for December 2025 showed that an order for Diphenhydramine HCl 25 mg by mouth every 24 hours as needed for itching at bedtime was transcribed on December 14, 2025 at 9:48 AM and discontinued the same day at 1:21 PM, with a new order for 0.5 tablet every 24 hours as needed at bedtime entered at 1:21 PM. Interviews with multiple LPNs confirmed that their usual practice is to verify a provider order before administering any medication, to transcribe the order into the electronic record, to document administration on the MAR, and not to leave medications at the bedside unless there is a self-administration order and assessment of the resident’s capacity. They stated that leaving medication at the bedside is against facility policy and could result in issues such as double dosing or access by other residents. The DON stated that the expectation for medication administration is to have provider orders and to administer and document medications according to those orders, with staff remaining with the resident until medications are swallowed. She reported being aware of the Benadryl issue and described a process for self-administration that requires assessment of competency and a provider order. The DON indicated that an order for Benadryl had been obtained via text message on a staff/provider work cellphone on a Saturday evening, that the nurse administered the medication, and that the resident bit the tablet in half and requested to save the other half. Facility documentation of the text message showed a provider response of “Yeah prn” to a request for Benadryl to sleep, but the message lacked a date stamp, dose, frequency, time, and route. There was no corresponding documentation in the electronic record or MAR that an order for Benadryl to sleep as needed had been received or that the medication had been administered at that time. Facility policies required that no medication be administered without a written, dated, and signed order including name and strength of the drug, dosage, frequency, route, and reason, that orders be recorded and transcribed into the eMAR, and that staff remain with the resident until medications are swallowed. The presence of Benadryl at the bedside without a documented, complete order and without a self-administration assessment and care plan constituted the deficient practice, which the report states could place the resident’s safety at risk.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported in a timely manner as required by policy and regulations. A cognitively severely impaired resident with multiple diagnoses, including major depressive disorder and hemiparesis, reported being inappropriately touched by another resident who was cognitively intact. The initial incident was documented in a nursing progress note, which stated that a CNA was informed by a resident about the inappropriate touching, and the charge nurse and DON were notified. However, the official report to authorities was not made until several days later, as indicated by the intake and 5-day report dates. Interviews with staff, including CNAs, LPNs, the ADON, and the DON, confirmed that the expectation is for immediate reporting of abuse allegations to the appropriate authorities. The DON acknowledged that the incident documented in the progress note was the same as the one later reported, attributing the delay to an agency nurse not following proper reporting procedures. Facility policy requires that all allegations of abuse, neglect, or misappropriation be reported to state or federal agencies within the required timeframes, which was not followed in this case.
Failure to Administer IV Antibiotics per Provider Order and Notify Provider
Penalty
Summary
A deficiency occurred when a resident with diagnoses including bacteremia, urinary tract infection, sepsis, and sacral decubitus did not receive IV antibiotic medication, Ceftaroline Fosamil, as ordered by the provider. The medication was scheduled to be administered every 8 hours for 29 days, but multiple doses were missed over several days, as documented in the Medication Administration Record (MAR) with a code indicating the medication was not given. Progress notes repeatedly referenced waiting for the medication from the pharmacy or its pending arrival, but there was no documentation that the provider was notified about the missed doses. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the expected protocol in the event of a missing medication was to notify the provider and document the action in the progress notes. However, review of the resident's medical record and progress notes did not show any evidence that the provider was informed of the missed antibiotic doses. The facility's medication policy also required provider notification in case of irregularities in medication administration, which was not followed in this instance.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide CPR According to Resident's Advanced Directive
Penalty
Summary
The facility failed to follow a resident's advanced directives by not providing Cardiopulmonary Resuscitation (CPR) as ordered for a resident with acute and chronic respiratory failure and hypoxia. The resident had a documented advanced directive and physician's order indicating full code status, requiring resuscitation and transfer to an acute hospital in the event of cardiac or respiratory arrest. The care plan included monitoring for respiratory distress and reporting changes to the physician as needed. On the night in question, the resident exhibited signs of respiratory distress, including low blood pressure and decreased oxygen saturation, and received medications accordingly. However, there was no documentation of follow-up on the effectiveness of interventions or notification of the physician regarding the resident's critically low blood pressure. During the overnight shift, the resident was found unresponsive and cold by a CNA, who was unaware of the resident's code status and sought guidance from an LPN. The LPN assessed the resident and determined that CPR was not necessary, stating the resident had clearly passed. No code was called, and CPR was not performed prior to the arrival of emergency medical technicians (EMTs). When EMTs arrived, they found the resident with sheets pulled over her body, no CPR in progress, and staff reported the resident was deceased. The EMTs assessed the resident and pronounced her dead, noting signs of dependent lividity and no trauma. Interviews with staff revealed confusion regarding the process for determining code status and initiating CPR. The CNA reported not knowing the code status and relying on the LPN for direction. The LPN and other staff described facility procedures for code situations, including checking code status and starting CPR until EMS arrives, but these procedures were not followed in this incident. Facility policies required initiation of first aid measures, including CPR, for life-threatening changes in condition, and documentation of all actions taken, which was not evident in the records reviewed.
Failure to Document Meal Provision for Resident
Penalty
Summary
The facility failed to provide meals according to regulations for a resident, leading to a deficiency in maintaining adequate nutritional status. The resident, who was admitted with multiple diagnoses including a left tibia fracture, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, had a care plan initiated to address malnutrition. The plan included dietary supplements and monitoring of meal consumption. However, documentation revealed that meals were not recorded as provided on two occasions, raising concerns about whether the resident's dietary needs were met. Interviews with staff indicated that activities of daily living, including meal provision, are supposed to be documented in the electronic health record. However, discrepancies in documentation were noted, with staff acknowledging that blanks in the records indicated services were not completed. The Director of Nursing confirmed that the lack of documentation for meal provision on two days was not due to a system glitch, suggesting a lapse in care delivery or record-keeping. This deficiency could potentially result in residents not meeting their dietary needs, as evidenced by the resident's grievance about meal concerns.
Removal Plan
- staff to be in-serviced on accuracy and completion of daily Point of Care/Activities of Daily Living.
- staff to be in-serviced on recognizing and reporting changes in ADL activity/ability.
- DNS or designee will conduct a daily review of POC/ADL documentation completion to ensure substantial compliance.
- DNS or designee will ensure that the nutrition report will be discussed and reviewed at the weekly nutrition meeting for the Interdisciplinary Team to recognize declines or changes in eating patterns and respond proactively to the changes as indicated.
- DNS or designee will report findings of reviews to the QAPI committee with additional follow-up and recommendation as needed until substantial compliance is achieved and maintained.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Healthcare Of Mesa | 0.1 mi | ★★★★★ | 3 | 0 |
| Alta Mesa Health And Rehabilitation | 0.6 mi | ★★★★★ | 0 | 0 |
| Mi Casa Nursing Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Citadel Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Montecito Post Acute Care And Rehabilitation | 1.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.