Cycle 1
Health 2024-05-09 · Fire 2024-05-09
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mesa, AZ
Desert Blossom Health & Rehab Center
4-star overall rating with 3-star inspections with $8,278 in total fines with 9 recent health deficiencies
60 South 58th Street, Mesa, AZ
(480) 832-3903
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-08-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,178
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9879
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.65
Baseline 20.59% · Performance 18.81% · Measure score 5.65 · Achievement 5.65 · Improvement 4.49
Healthcare-associated infections
4.29
Baseline 6.89% · Performance 6.55% · Measure score 4.29 · Achievement 4.29 · Improvement 1.27
Total nurse turnover
2.66
Baseline 64.89% · Performance 52.81% · Measure score 2.66 · Achievement 2.66 · Improvement 2.52
Adjusted total nurse staffing
0.90
Baseline 2.97 hours · Performance 3.33 hours · Measure score 0.90 · Achievement 0.90 · Improvement 0.79
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.96% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 8% · Lower 95% interval 6.5% |
| Discharge to community | 60.29% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 85 · Observed rate 60% · Lower 95% interval 51.42% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 85 · Denominator 85 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 85 |
| Discharge self-care score | 54.9% |
53.69%
1.2 pts better
|
Numerator 28 · Denominator 51 |
| Discharge mobility score | 47.06% |
50.94%
3.9 pts worse
|
Numerator 24 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 85 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 3.33% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 17.67% |
42%
24.3 pts worse
|
Numerator 38 · Denominator 215 |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 30 · Denominator 51 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 57 · Denominator 57 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 4 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.7% |
97.1%
22.4 pts worse
|
93.4%
18.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 72.3% · Q3 71.1% · Q4 76.4% · 4Q avg 74.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.6%
0.2 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.1%
1.6 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
4.2%
0.5 pts worse
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.8% · Q3 0.0% · Q4 4.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who lose too much weight | 10.7% |
5.3%
5.4 pts worse
|
5.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 20.5% · Q3 4.9% · Q4 8.2% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.5% |
20.5%
13 pts worse
|
19.6%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 33.3% · Q3 31.7% · Q4 40.0% · 4Q avg 33.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
11.8%
8.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 7.7% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.8% |
14.5%
11.7 pts better
|
16.3%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.3% |
10.8%
9.5 pts better
|
14.9%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.2%
1.4 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.4% · Q3 2.2% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
20.5%
0.3 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.8% · Q2 36.8% · Q3 11.0% · Q4 14.2% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.8%
1.5 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.0% · Q3 3.5% · Q4 3.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
91.1%
4.7 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 95.4% · Q3 98.7% · Q4 97.4% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
10.7%
2.6 pts worse
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 17.6% · Expected 14.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
1.1%
1 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
87.3%
4.4 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.7% |
24.6%
10.1 pts worse
|
23.9%
10.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.7% · Observed 44.1% · Expected 30.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-06 · Fire 2023-01-06
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
7 health deficiencies
Top issue: Quality of Life and Care (3 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
2023-01-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-18
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 2025-08-22
D · Potential for more than minimal harm
2025-07-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-18
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 2025-08-22
G · Actual harm
2025-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-22
D · Potential for more than minimal harm
2024-05-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-05-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-05-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-21
D · Potential for more than minimal harm
2024-05-09
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 2024-07-20
E · Potential for more than minimal harm
2023-04-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-01-06
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 2023-02-20
D · Potential for more than minimal harm
2023-01-06
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 2022-12-01
E · Potential for more than minimal harm
2021-12-02
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 2022-01-16
E · Potential for more than minimal harm
2021-12-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-16
E · Potential for more than minimal harm
2021-12-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-12-02
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 2022-01-16
D · Potential for more than minimal harm
2021-12-02
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 2022-01-16
D · Potential for more than minimal harm
2021-12-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-01-16
Penalties and ownership
What sits behind the stars
$8,278
2025-06-02
Fine
Fine · fine $8,278
Fine
Ownership
Bandera Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Petty, Scott
Operational/Managerial Control · Individual
Petty, Scott
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Advanced Healthcare Of Mesa
Mesa, AZ
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Alta Mesa Health And Rehabilitation
Mesa, AZ
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Mi Casa Nursing Center
Mesa, AZ
3-star overall rating with 2-star inspections with abuse icon flag with $6,510 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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