Inspection Reports for
Desert Blossom Health and Rehabilitation

The complaint investigation was triggered by an allegation that Resident #100 touched Resident #12 inappropriately. The facility failed to report this allegation promptly as required. The investigation revealed delays and inconsistencies in reporting and handling the abuse allegation, including a nursing progress note predating the official incident report. The facility also failed to notify providers about missed medication doses and had discrepancies in narcotic drug counts.

The facility failed to timely report suspected abuse, ensure medications were administered per provider orders, provide appropriate pain management, and maintain accurate controlled drug records. Deficiencies involved failure to report an abuse allegation promptly, missed IV antibiotic doses without provider notification, inadequate pain medication administration, and discrepancies in narcotic counts.

The complaint investigation found that CPR was not performed on Resident #21 despite being a full code. Staff failed to notify the physician, delayed EMS notification, and did not follow proper code procedures. The resident was found cold and unresponsive, and EMS pronounced death. The investigation included multiple staff interviews and review of clinical records and policies.

The facility failed to provide CPR to Resident #21, who was a full code, after being found unresponsive. Staff did not initiate or continue CPR properly, delayed calling EMS, and there was confusion about pronouncing death. The resident was pronounced deceased by EMS. The facility conducted interviews and reviewed policies, noting staff misunderstandings and a subsequent mock code training.

The facility failed to ensure that meals and dietary supplements were consistently provided and properly documented for resident #76, who was malnourished. Documentation gaps were identified, with some meals not recorded as provided, and the facility implemented corrective measures including staff in-service training and enhanced monitoring of documentation.

The facility was found deficient in maintaining safe and comfortable room temperatures for residents, ensuring medication services met professional standards, providing adequate nutrition documentation and meal provision, and maintaining accurate nursing documentation of resident care and incidents.

The facility failed to ensure identification and addressing of nutritional risk factors for resident #1, resulting in inadequate monitoring and reporting of meal intake and missed meals. The resident experienced significant weight loss and was not provided adaptive feeding equipment or assistance as needed. Documentation and communication regarding nutritional status and intake were deficient.

The complaint investigation focused on medication availability and administration for resident #261 and documentation of continence care for resident #266. The medication issue was substantiated with findings of missed doses and lack of follow-up communication. The continence care documentation deficiency was substantiated with evidence of missing documentation and was addressed through the facility's Quality Assurance process.

The facility failed to ensure that medications were available as ordered for one resident, resulting in missed doses of anastrozole. Additionally, the facility failed to adequately document continence care for another resident, leading to incomplete clinical records. Both deficiencies were associated with minimal harm or potential for actual harm and affected a few residents.

The investigation was complaint-driven, focusing on issues such as failure to notify physicians, lack of care plans, inconsistent personal care, missing physician orders, improper medication administration, and inadequate call systems.

The facility failed to notify a physician of a resident's high blood sugar, develop care plans for CPAP/BIPAP use and protective mats, provide consistent bathing and oral care, ensure physician orders for oxygen and CPAP/BIPAP use, administer pain medication within ordered parameters, and maintain a working call system in a shower room. These deficiencies posed risks of inadequate care, potential harm, and communication barriers for residents.