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Desert Gardens Nursing And Rehabilitation Center

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About Desert Gardens Nursing And Rehabilitation Center

General Information

Legal Business NamePinnacle Health Facilities Xxxiv Lp
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareMarch 29, 2002 (15 years)
Capacity106
Residents87
Percent Occupied82%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Desert Gardens Nursing And Rehabilitation Center

Desert Gardens Nursing And Rehabilitation Center
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

July 21, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionLet residents voice a complaint or grievance without being treated differently or badly.
FManyPotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
FManyPotential for HarmComplaint+InspectionTry to resolve each resident's complaints quickly.
ESomePotential for HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionMaintain comfortable and safe temperature levels.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.

July 17, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
FManyPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
ESomePotential for HarmFire Safety InspectionSigns that state that exit doors are to be kept closed.

June 18, 2015 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
HSomeActual HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
HSomeActual HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmComplaintGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
ESomePotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
CManyPotential for Minimal HarmComplaintSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.

May 19, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.

March 11, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 124 days
---Fine$92,496 fine
KSomeImmediate JeopardyComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
KSomeImmediate JeopardyComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
HSomeActual HarmComplaintEnsure that residents are safe from serious medication errors.
ESomePotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
ESomePotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
BSomePotential for Minimal HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.

June 6, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
CManyPotential for Minimal HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

June 5, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
FManyPotential for HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
CManyPotential for Minimal HarmFire Safety InspectionAt least two remote exits on each floor or fire section of the building.
CManyPotential for Minimal HarmFire Safety InspectionExits that are accessible at all times.
CManyPotential for Minimal HarmFire Safety InspectionSigns that state that exit doors are to be kept closed.

April 23, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintPermit residents to remain in the facility and not be transferred or discharged without adequate reason.

February 26, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintKeep residents' personal and medical records private and confidential.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Desert Gardens Nursing And Rehabilitation Center require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

1hr 50min
2hr 50min
ReportedExpected
CNA
50min
45min
ReportedExpected
LPN
35min
1hr 10min
ReportedExpected
RN
3hr 10min
4hr 45min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.8%
96.7%
96.7%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
98.8%
100.0%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
-
96.9%
76.5%
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
24.0%
23.7%
25.4%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
17.4%
5.5%
11.6%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
16.0%
15.8%
3.0%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
1.3%
1.2%
7.7%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
9.0%
8.6%
5.3%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
19.2%
18.2%
12.8%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
1.2%
0.0%
0.0%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
3.7%
3.6%
1.3%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
0.0%
1.4%
0.0%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

97.4%
96.9%
100.0%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
100.0%
100.0%
100.0%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
-
16.5%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
8.7%
0.0%
0.0%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
1.5%
1.6%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened